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Full text of "The Medical and surgical reporter"

The 

edical and surgical 
Reporter. 



EDITED BY 

Harold H. Kynett, M. D. 



JULY TO DECEMBER, 1892. 



VOL. LXVII. 



Philadelphia : 
R. C. PENFIELD, PUBLISHER, 
P. 0. BOX S43. 
1802. 



CONTRIBUTORS. 



ADLER, LEWIS H., Jr., M. D., Philadelphia, Pa. 
ANDERS, J. M., M. D., Ph. D., Philadelphia, Pa. 
ARNOLD, H. A., M. D., Ardmore, Pa. 
AYERS, SAMUEL, Pittsburg, Pa. 

BENEDICT, A. L., A. M., M. D., Buffalo, New York. 
BENNETT, WILLIAM H., F. R. C. S., Eng., London. 
BISHOP, LOUIS F., M. D. 
BL AILOCK, W. R., M. D., McGregor, Texas. 
BLOOM, I. N., M. D., Louisville, Ky. 
BORLAND, E. B., M. D. 
BO WEN, A., M. D., Nebraska City, Neb. 
BROK A W, A. V. L. M. D., St. Louis, Mo. 
BROWER, D. R , M. D., Chicago, III. [Pa. 
BRYAN, JAY MUSSINA, M. D., Fountain Springs, 
BUCHANAN, CHARLES M., M. D., Washington, 
D. C 

CAREY, CHARLES., M. D., Buffalo, N. Y. 
CARTLE DOE. A. M., M.D., Louisville, Ky. 
CECIL, J. G., M. D., Louisville, Ky. 
CHEATHAM, WILLIAM, M. D., Louisville, Ky. 
CHRYSTIE, T. M. LUDLOW, M. D., New York City. 
CLINE, LEWIS C, M. D., Indianapolis, Ind. 
COLTMAN, ROBERT, Jr., M. D. 
CRAlNTDALL, JONH B.,M. D., Sterling, 111. 

DABNEY, S. G„ M. D., Louisville, Ky, 
DALAND, JUDSON, M. D., Phila., Pa. 
DANA, C. L., M. D., New York. 
D AAV BARN, DR, R. H. M., New York, 
DEAN, GEORGE R., M. D„ Spartanburg, S. C. 
DEROUM, CLARA T., M. D., Phila., Pa. 
DOW LING, FRANCIS, M. D., Cincinnati, 0. 
DUNSMOOR, F. A., M. D., Minneapolis, Minn. 

EASLEY, E. P., M. D., New Albany, Ind. 
EICHLER, A., M. D., San Francisco, Cal. 
EVANS, JAMES, M. D., Florence, S.C. 

FARNS WORTH, P. J., A. M., M. D., Clinton, Iowa. 
FELL. GEORGE E., M. D., F. R. M. P., Buffalo, N. Y. 
FREGHAM, DR., Berlin, Germany. 

GIBSON, GEORGE HOMER, M. D„ Denver, Col. 
GILLIAM, D, TOD., M. D., Columbus, Ohio. 
GOGGANS, JAMES A., M. D., Alexander City, Ala. 
GRATTAN, NICHOLAS, F. R.S. C, Ed. 
GRUTE, R. H., M. D. 

HAGGARD, W. D., M. D., Nashville, Tenn. 
HARKIN, E. H., M. D., India. 
HOPPEL, T. J., A. M., M. D., Trenton, Tenn. 
HARRIS, ROBERT, A. M., M. D., Phila., Pa. 
HIRST, BARTON COOKE, M. D., Phila. Pa. 
HOBBS, ARTHUR G., M. D., Atlanta, Ga. 
HOVENT, Dr., Brussels, Belgium. 
HUGHES, C. H., M. D., St. Louis, Mo. 
HYDE, 0. A., M. D., New York, N. Y. 

INGALS, E. FLETCHER, M. D., Chicago, 111. 
IRWIN, J. W., M. D., Louisville, Ky. 

JACKSON, EDWARD, M. D., Philadelphia, Pa. 
JEWELL, P.M., M.D., Ossian, Iowa. 



KELLOG, E. W., M. D., Milwaukee, Wis. 
KELLY, HOWARD A., M. D., Baltimore, Md. 
KOENIG, ADOLPH, M, D. 
KORTE, Dr. W., Berlin, Germany. 

LANPHE AR, EMORY, M. D., Ph. D. Kansas City, Mo. 

LAY, F. H., M. D., Denver, Col. 

LEHLBACH, CHAS., F. J., M. D., Newark, N. J. 

LEONARD, P. I , M. D., St. Joseph, Mo. 

LEONHARDI, F., M D., Dresden, Ger. 

LINK, W. H., A. M., M. D., Petersburg, Indiana. 

LYDSTON, G. FRANK, M. D., Chicago, 111. 

McKELWAY, GEORGE I., M. D., Phila,, Pa. 
MANLEY, THOMAS H , M. D., New York, N. Y. 
MANN, M D., M. D., Buffalo, New York. 
MANSFIELD, A. D., Baltimore, Md. 
MASSEY, G. BETEON, M. D., Phila., Pa, 
M ATTTSON, J. B., M. D., Brooklyn, N. Y. 
MILLER, KATHERINE, M. D., Lincoln, 111. 
MIRGIS, GEORGE, M. D. 
MONTGOMERY, E. E., M. D., Phila., Pa. 
MUNFORD, S. E., M. D., Princeton, Ind. 
MYERS, J. D., M, D., Huntington, W. Va. 

NORBURY, FRANK PARSONS, M. D.. Jacksonville, 
111. 

NOTHNAGEL, Prof. H., Vienna, Austria. 

OLSHANSEN, ROBERT, M. D., Berlin, Germany. 

PARK, ROSWELL. M. D , Buffalo, New York. 
PERKINS. C. E., M. D., SANDUSKY, Ohio. 
PETER, ROBERT, M. D., Canal Dover, Ohio. 
PHELPS, A. M., M. D., New York, N. Y. 
PRICE, JOSEPH, A. M., M, D., Phila., Pa. 
PRYOR, J. E., M. D., Ocean City, N. J. 

RENDU, Dr., Paris, France. 
RIKER, J. D., B. L., M. D., Pontiac, Mich. 
ROBINSON, FRED BYRON, B. S., M. D„ Chicago, 
111. 

ROCKWELL, A. D., M. D., New York, N. Y. 
RODGERS, MARK A., M. D., Allegheny, Pa. 
ROSS, ALICE MAC L., M. D., Swatow, China. 

SIMPSON, A.R., M.D., Edinburgh, Scotland. 
SHAFFER, J. M., M. D., Koekuk, Iowa. 
SHAW, CHARLES S., M. D., Pittsburg, Pa. 
STIMPSON,A. 0., M. D., C. M., Thompson, Pa. 
STOCKTON, CHAS. G., M. D., Buffalo, N. Y. 
SWAIN, HENRY S., M.D., New Haven, Conn. 

TOWER, FRANKLYN J., M. D., Milwaukee, Wis. 
TOWLER, S. C, M. D., Marienville, Pa. 

VEASEY, C. A., M. D., Philadelphia, Pa. 

WARREN, A. E., M. D., Girard, Ohio. 
WILEY, P. N., M. D„ Norristown, Pa. 
WILLIAMS, D. H., M. D., Knoxille, Tenn. 
WILSON, H. AUGUSTUS, M. D., Phila., Pa. 

YOUNG, W. B., M. D., Bon Air Coal Mines, Tenn. 



INDEX. 



Abdominal — Growths, 764. 
Massage, 423. 

Tumors, Supposed to be Ovarian, Goggans, 179. 

Wound, Spontaneous Cure of, 434. 
Abortion — A Landmark of Gynaecology, Robinson, 60S. 

Chlorate of Potash in Habitual, 63.5. 

Its Treatment, Webb, 1043. 

Missed, 595, 1026. 

Treatment of, 570. 
Abscesses — In Medulla Oblongata, 309. 

In Pneumonia, Artificial Production of, 470. 
Acetonemia, 71. 

Aconite, Crystalized Nitrate of, 347. 

Acute Cerebral Meningitis Subsequent to Spontaneous 

Abortion, 850. 
Acute Oophoritis as a Sequel of Influenza, 314. 
Addison's Diseases, 428. 
Adenoid Tumors, Statistics of, 312. 
Adenoid Vegetation, Symptoms Produced, 117. 
Adler, Lewis H., Jr., 450, 927. 
Adulterators, Punished, 319. 
Oesophageal Diverticulum, Excision of, 548. 
A Few Notable Remedies, Munford, 261. 
After Pains, Amyl Nitrate for, 608, 
Agnew, D. Hayes, Biography of, 120. 
Albumin. Reagent for, 199. 
Albuminira — To Psyehoses, Relation of, 472. 

As Means of Diagnosis, 676. 
Alcohol. Its Value in Diseases (Prize Essays), 597. 
Alcoholism — And its Treatment by Strychnine, 791. 

Insomnia of, 633. 

Treated by Drugs, 702. 
Alopecia Areata, 513. 

Therapeutic Note on, 108. 
Alum in Drinking Water, Delicate Test for, 40. 
Amenorrhoea, 596. 

American " Crowbar and Skull Case," 936. 
American Dermatological Association, 319. 
American Electro Therapeutic Association, 479. 
Amputated Limbs, Ownership of, 160. 
Anal Fissure — or Irritable Ulcer of the Rectum, the 
Treatment of, Adler, 927. 
and Rectal Stricture, 317. 
Analin Stains, To Remove from the Skin, 32. 
Anaethesia, Local, 633. 

Anaesthetics in Obstetrics, The Value of, 909. 

Anders, J. M., 361. 

An Educational Need, Price, 819. 

Animal Diphtheria, To Man, On the Contagion of, 747. 
Animal Tissues, Extracts of. 160. 
Ankylostomiasis, The Beriberi of Assam, 194. 
Antifebrin, Poisoning by, 749 
Antinervine (salicylbromanilide), 348. 
Antipyrine, 109. 

And Euphorine, 80. 

Blackening of the Teeth, by, 831, 311. 

In Epistaxis, 781. 
Anti-Rheumatic, 110. 
Antiseptic Mixtures, 155, 347, 633. 
Antiseptics And Behavior toward Salivary Digestion , 

398. 



Antisepsis in Ophthalmology, 354. 
Aphthous Stomatis, Etiology of, 478. 
Apostolis Methods, 826. 

Appendicitis — Pathognomonic Signs of Perforating, 

635. 

Masked and Complicated by Ovarian Adhesions, 
McKelway, 602. 

Treatment of, 832. 

And McBurney, 678, 387, 594. 
Aristol and Europhen, Eichler, 53. 
Arteries, Torsion of, 517. 
Arsenic as a Prophylactic, 1017. 
A Source of Danger, 873. 
Asphyxia — In New-born Children, 115. 

In the New-born, Treatment of, 36. 
Ascites in Women, 77. 

Association of Hospital Physicians and Surgeons of 

Philadelphia, 320. 
Asthma, 572. 

Mechanical Treatment of, 307. 

(Hay), Euphorbia Piluligera in, 307. 

Its Intra-Nasal Origin and Surgical Treatment, 
Swain, 287- 
Atheromata, Treatment of, 146. 
Atraetylis Gummifora, Poisoning by, 73. 
Atrophic Rhinitis, The Etiology of, 828. 
Atrophine and Morphine, 543. 

As a Hemostatic, 629. 

As a Haemostatic, 309. 
Aural — Catheter Steam Sterilizer, 549. 

Retractor, 146. 
Avine Tubercle versus Human Tubercle, 198. 
Ayres, Samuel, 18. 

Bacillus of Typhoid Fever and Bacillus Coli Mon- 

nanis (distraction between,) 356. 
Bacteria of Melons, 398. 
Bacteriological Notes, 700, 620, 735. 
Beef Juice, 867. 

Beef and Fish, Digisti Vility of, 871, 

Belladonna in First Stage of Labor, 358. 

Benedict, A. L., 573. 

Bennett, William H., 481, 

Beri Beri. Pathogenesis of, 349. 

Biliary Duct — Catheterization of, 592. 435. 

B diary Passages, Catheterism of, 433. 

Bishop, Louis, bangeres, 

Bismuth — Bengoateg, 479 

Sub-nitrate in Burns — New Mode of Employ- 
ment, 829. 

Bicyclists. Catarrhal Laryngitis of, 596. 

Black, Carl E., 991. 

Black Eye, 789. 

Bladder, Rupture of, 550. 

Blailock, W. R , 679. 

Blood— Changes in, 711. 

Examinng specemins of, 557. 

In Puerperal Seps s, 157. 

Specific gravity of, 34. 

Clot Treatment of Aneurism and Haemorrhoids, 

987. 



Index. 



iii 



Bloom, I. N., 454. 

Bone Grafting, successful case, 40. 

Book Notices. 
Allen, Mastoid Operations, Including its History, Ana- 
tomy and Pathology, 828. 
Adler, Fissue of the Anus and Fistula in Ano, 904. 
Annual Report Philadelphia Bureau of Health, 990. 
Brainard, Medical Society of Wisconsin, 378. 
Billings, Public Scandal A, 989. 
Beach, Histology, Pathology and Bacteriology, 904. 
Bulkley, Acne and Alopecia, 828, 904. 
Bell, A Manual of the Operations of Surgery. 628. 
Brockway, Anatomy, 904. 
Billings, A Public Scandal, 828. 

Blanchard, Surles Estricles Americans, 628. 
Br a teuahl, Gynecology, 674. 

M rs Sawyer, Souvenir of Asheville or Sky Land, 828. 
Miller, etc., Diseases of Eye, Ear and Throat, 989. 
Miller, Die Mikroorganismen der Mundhahle, 989. 
Materia Medica and Therapeutics, Including Whole 

Remedies of British Pharmacopgeia and Appendix, 

513. 

Mental Diseases, 674. 

Medical and Surgical Gynecology, 191. 

Medical News Visiting List, 1893, 904. 

Medical and Dental Register, Directory and Intelli- 
gence of Pa., N. J. and Del,, 628. 

McNutt, Disease of the Kidney and Bladder, 789. 

Matthews, A Treatise on Diseases of the Rectum, 989. 

Manual of the Operations of Surgery, 674. 

Mitchell, Characteristics, 674. 

Nolte Lewis G., Milwaukee, Wis. 

One Thousand Prescriptions, 990. 

Park, Roswell, Prof., Buffalo, N. Y., 23. 

Pan-American Medical Congress, 539. 

Physicians' Yisting List, 1893, 990. 

Practical Midwifery, 146. 

Principles and Practice of Bandaging, 674. 

Pronouncing Dictionary of Medicine, 513. 

Proceedings of the Fourth State Sanitary Convention 
of Pennsylvania, 990. 

Physicians' Pocket Diary, 990. 

Physicians Complete Book of Records, 706. 

roceedings of Philadelphia County Medical Society 

Pfor 1891, Vol. XII, 674. 

Peddie, a Manual of Physics, 747. 

Page, R. C. M., Practice of Medicine, 29. 

Rhodes, Diseases of Children, Students' Quiz Series, 
904. 

Stevens, a Manual of the Practice of Medicine, 989. 

Solis-Cohen, Essentials of Diagnosis, 628. 

Senn, Tuberculosis of Bones and Joints, 747. 

Seiffert, Consumption and Kochine, Original Observa- 
tions and Reports Based on Individual Experience, 
904. 

Science and Art of Midwifery, 385. 
Local Boards of Health, 990. 

Transactions of the American Otological Society, 990. 
Text-Book of Diseases of the Skin, Shoemaker, 674. 
Varicocele and Its Treatment, 275. 
Wilson, Handbook of Hygiene and Sanitary Science, 
828. 

Wharton, Henry R., Philadelphia. 

Chadwick, Temperment, Disease and Health, 628. 

Cancer and its Treatment, Daniel, 30. 

Cathell, Book on the Physician Himself, 628. 

Currier, Jno. M., Newport, Vt. 

Canfield, Hygiene of Sick-room, 749. 943. 

Chapman, A Manual of Medical Juris-prudence and 

Toxicology, 789. 
Cerebran, Meningitis, 345. 

Diseases of Urinary Apparatus, Phegmatic Affections, 
107. ■ 

Doubleday, Practice of Medicine, 674. 
G. E. de Schweinitz, Diseases of the Eye, 72. 
Davenport, Diseases of Women, 747, 942. 
Davis the Physicians' Leisure Library, 904. 
Davis, Diseases of the Lungs, Heart and Kidneys, 942, 
747. 



Davis and Keating, Mother and Child, 989. 

Dana, Text-Book of Nervous Diseases, 904. 

Ewart, Cardiac Outlines for Clinical Clerks and Practi- 
tioners, and First Principles in the Physical Ex- 
amination of the Heart, for the Beginner, 528. 

Epitomized Review of Principles and Practice of 
Maritine Sanitation, 421. 

Fuch's Text-Book of Ophthalmology, 828. 

Hayt, Obstetrics, 674. 

Ingalls, Diseases of the Chest, Throat and Nasal Cavi- 
ties, 904. 

Irwin, Hydrotherapy at Saratoga, 628. 
Introduction to the Antiseptive Treatment of Wounds, 
421. 

Keating, etc., International Clinics, 989. 

Jackson, The Ready Reference Handbook of Diseases 
of the Skin, 747. 

James, Alaskana or Alaska in Description and Legen- 
dary, 828. 

Keen, an American Text-Book of Surgery, 989. 
Kenner, Contributions of Physicians to English and 

American Literature, 628. 
Lydston, Gonorrhoea and its Treatment, 674. 

Borland, E. B., 332. 

Boorel Occlusion, Dean, 885. 

Bowen, A., 225. 

Brain Abscess resulting from Suppuration Otitis 

Media, 908. 
Breast— Excision of, 115. 

Milk, Examination of, 439. 
Bright's Disease, strontium Salts in, 629. 
Brokaw, A. V. L. 922. 
Bromide of Ethyl Narcrosis, 347. 
Browers, D. R. 95. 
Bryan, Jay Mussina, 331, 
Buchanan, Charles M., 468, 884. 

Buboes — Treatment of by Injection of Iodoformized 
Vaseline, 32. 

By Welanders Method, Abortive Treatment of, 
897. 

Buffalo Lithia Water in the Treatment of Renal 

Calculi, 910. 
Burns, Complication and Death after. 552. 

Cassarean Section, 436. 

In Extremis and After Death, 36. 

In Placenta Iravaea, 670. 

Technique of, 713. 
Caluclus from Vermiforn Appendix, Removal of, 508. 
Calomel — As a Diuritic, 623. 

Injections, Mode of Action of, 947. 
Calumba, Tincture of, Action and Use of, 32. 
Camphor, New Solvent of, 40. 
Camphorated Oil, Action of, 73. 
Cancer— 422. 

In Relation to Insanity, 457. 

Transmission of, 239. 

Of Vagina, 159. 

Uterine, 667. 
Cannabis Indica, 637. 

Casut Coli, Inflammation About the Lydston, 757. 
Carbolic Acid Poisoning, 513. 
Carcinoma — Transmissibility of, 79. 

Of Brain, Secondary to that of Breast, 546. 

Of Breast, recurrence of, 110. 
Cardiac Disease, Dietic Treatment of, 149. 
Carricura Pigeons and Vaccination, 455. 
Carteledge, A. M., 652. 
Caster Oil, 778. 

Aromatie, 147. 
Catgut— Evils of, 792. 

Sutures, 978. 
Catheter, Straight Tube the Simplest, 908. 

Fixation of, 1023. 
Catheterism in the Female, 978. 
Cavazzani's Antiseptic Powder, 188. 
Celluloid Buttons, Danger of, 358. 



iv 



Index. 



Cerebral — Circulation During Hypnosis. 194. 
Surgery, 709. 

Syphilis, Precocious, Hereditary of, 33. 
Cerebillar Tumor, 150. 
Cerebro Spinal Meningitis. 316. 
Chancre, Soft, Bacillus of, 555. 
Chancroid, Inoculation of, 317. 

Changes in the Cerebullum, Result of Cerebral Hydro- 
cephalus, 385. 

Cheatham William, 256. 

Chicago Medical l?ecord,Z99. 

Chicago, Sanitary Condition of, 871. 

Chloralamid in Sea-sickness, 907. 

Chlorate of Potash, Poisoning by, 175. 

Chloride— of Ethyl, 307. 

Of Gold and Sodium in Progressive General Par- 
alysis, 297. 

Chloroform — Extreme Case of Suspended Animation, 
Prince, 584. 
Effects of. 147. 
Internally, 449. 
Some Internal Uses of, 947. 
Syncope, 233. 

Chlorosis — Injections of Ammonio, Citrate of Iron in, 
423. 

Sulphur in, 630, 198. 

Washing Out Stomach in, 620. 
Cboledockotomy, 488. 
Cholera— Cacilli, Bottling up, 80. 

Chemistry of, Kramer, 530, 

Diagnosis and Treatment of, Osier, 537. 

Etiology of, Evans, 532. 

Pathology of, Freeman, 534. 

And how to Prevent it, 581. 

Notes. Werner. 

Treatment of in the Altoona Hospital, 1017. 
Chorea, 46. 

Artificial, 439. 

In Hospitals of Paris, 238. 

Hysterical Arythmic, 75. 

Of Pregnancy, 475. 

Treatment of, 78. 
Chronic Dysentery, Aristol in, 386. 
Chronic Dyspeptic States Treated by Menthol Spray 

Through Stomach Tube, 1015. 
Chronic Purulent Otitis Media, Boric Acid in Treat- 
ment of, 306. 
Chrystine, T. M. Ludlow, 448. 

Cimicifuga in Dysmenorrhoea and Ovarian Irritation, 
196. 

Circulation in the Brain and Eye, with Increased Pres- 
sure and Glancoma, Leonard, 135. 
Cline, Lewis C, 259. 

Club foot — Operative Treatment of Hip-joint Disease, 
Diagnosis and Treatment of, Phelps, 46. 

Cocaine, 588. 

Abuse of, 439. 
Antidotes, 829. 

In Intra-uterine Injection, 315. 
Poisoning by, 341. 
Poisoning, 728. 

Uses and Abuses of, with reference to Mucous 
Membranes especially, Hobbs, 639. 
Cochlea, Functional Importance of, 431. 
Coedine. Fflfect of Overdose, 368. 
u Coeliotomy " versus " Laparotomy," 607. 
Cold in the Head, 568, 944. 
Coltman, Jr., Robert, 441. 

Collapse after Ovariotomy, Transfusion , Recovery, 1015 
Comminuted Fracture of the Shaft of the Femur, Lay, 
408. 

Common Boils and Carbuncles, Farnsworth, 377. 
Common Bile Duct, Carcinoma of the, 1021. 
Compress left after Abdominal Section, 354. 
Concussion of Brain, Mechanism of, 549. 
Congenital — Baldness and Pemphigus, 711. 

Fistula of the Neck, 317. 
Congress — Eleventh International, 678. 

Of Tuberculosis in 1893, 556. 



Conservatism in Gynecology. Link, 953. 
Conservative, The, Fowler, 1008. 
Convulsions at Six Months, 1025. 

In Children, 1019. 
Copper in Adynamic Anaemia, 500. 
Cornea — Foreign Bodies in, Jackson, 655. 

Infectuous Ulcers of Iodine in, 192. 
Corneal— Ulcerations, Tincture of Iodine in, 42.3. 

Ulceration and its Sequelee, Mansfield, 800. 
Coronilla, 149. 

Correction Dawbarn's Lecture, 515. 
Corrosive Sublimate, Douche, 754. 

Counter-Irritation, in Treatment of Haemorrhages, 
1018. 

Crandall, Jno. B., 56. 
Cranial — Auscultation, 427. 

Bones, Hyperesthesia of, 475. 
Creasote and its Elements, 279. 
Cremation, Progress of, 318. 
Crematory for Berlin, 280. 
Cross Paralysis, 153. 

Croup — Diphtheria and Scarlet Fever, 770. 

Oleum Terebinthinaj as a' Remedy, Kellogg, 57. 

Primary, Etiology of, 330. 

Treatment of, 1019. 
Coroupous Rhinitis, 471. 

Crowds, Diseases and Accidents of great, 793. 
Curetting the Uteras, 316. 
Currier, John M., 421. 

Cysts and Abscesses, Treated of by Papoid and Per- 
oxide of Hydrogen, Hyde, 20. 
Cyst of Middle Turbinated Bone, 434. 
Cystectomy for Polycystic Ovarian Tumor, Kelly, 241. 
Cystitis in Women, Treatment of, 942. 

Dabney, S. G., 645. 
Dacryocystitis, 435. 

Operative Treatment of, 114. 
Da Costa. Prof., 319. 
Dana, C. L., 126. 
Dandruff, 232. 

Dawbarn, R. H. M., 207, 515. 

Deafness of Long Standing Cured in a few Days, 

Hornet, 878. 
Deaf Mutism, 353. 
Dean, George R., 885. 
Dearer, John B., 962. 

Death — After Retroflexion of Gravid Uterus, 396. 

After intravauterine injection, 116. 
Deformity of Knee, Wilson, 599. 
Delirium Tremens, Treatment of, 102S. 
Dementia, Myelin Nerve Fibers in, 591. 
Dentition in Infants, 701. 
Dercum, Clara T. 

Dermatol in Surgical Practice, 549. 
Dermoid Cyst, Containing a Heart, 714. 
Diabetes Mellitus, A New Remedy in, 943. 
Diabetes — and functions of female organs, 196. 

Aleuronat as a food in, 590. 

Mellitus, by Fright, 589. 

Diet in, 1020. 
Diabetic Urine Testing, 119. 
Diaphragmatic Hernia, 332. 
Diarrh oaa— Infantile, Glyceriting Borax in, 551. 

Infantile of Warm Countries, 551. 

Use of Strychnine and Digitalis in, 1017. 
Diarrhoeal Collapse, Subcutaneous Infection of salt 
in, 425. 

Digestive Organs, Method of Examination of, 382. 
Digitalis in Aortic Disease, 307. 
Digitaline, 469. 
Diphtheria, 782, 426. 

Convalescent be Isolated/How long should a, 239. 

Antipyrine Treatment by, 317, 117, 

With Arsenite of Copper, Treatment of, 794 

Treatment of, 806, 867. 

«ilver Nitrate in, 753. 

Epidemic caused by Ice, 950. 



Index. 



v 



Permangarate Potassium in the Treatment of, 831, 
^Etiology and Bacteriology of, Tower, 181. 
Case by Isolated, How long should a, 796. 
Infections, Erytherra in, 753. 
And Croup, 477. 

And Membraneous Pharyngitis, 1019. 

Bacillus, Antipyrin Action on, 588. 

Invasion of, 117. 

Methyl Violet in, 753. 

Ingals, 11. 

Angina, 348. 

Result of, 572. 

Tracheotomies for, 1024. 
Diphtheretic Paralysis Treatment of, 747. 
Disease of the Knee-joint in its Convalescence, Chrys- 

tine, 488. 
Disinfectant, 625. 

Dislocations of Great Toe and Thumb, Irreducible, 
473. 

Diuretic Drugs, on certain, 783. 
Diuretin in Infantile Practice, 30. 
Doctor as a Debtor. 518. 

Does Influenza Protact from a Subsequent Attack? 
278. 

Double Haemorrhagie subdural Cyst, 376. 
Dowling, Frances, 642. 

Drainage Tubes in Wounds, Objection to, 235. 
Drunkenness — As a Virtue, 253. 

In Women, Increased, 400. 
Dubosine Sulphate, 544. 

Dysentery as it Occurrs in Nicarauga, A Clinical 

Description of, 847. 
Dysmenorrhoea and Painful Ovaries, Warren, 499. 
Dyspnoea, Caused by Tumor of Neck, 75. 
Dystochia from Impaction of the Shoulders, 579. 



Ear — Blow Upon — death, 355. 

Affections, demarol, use of in, 544. 

How to poultice the, 792. 
Early Diagnosis and Early Operation — Plain Talks. 
739. 

Earth Worms and Tuberculosis, 553. 

Easley, E. P. 262 

Eclampsia — Olshansen, 41, 81, 1. 

Bacillus of, 37. 

And Septicaemia, 94. 
Ectopic Gestation, Actual, Not Text Book, Experi- 
ence With cases of, 736. 

Editorial. 

Abscess of the Liver, Treatment of, 106. 

Anatomy of Tonsils with Reference to their Surgical 

Treatment, 27. 
Announcement, 509. 
Antivivisection, 745. 
Carbolic Acid, Gangrene, 1S9. 
Complicated Fractures, 705. 
Cholera, 541. 

Inoculation Against, 587. 
Cocoaine and its Danges. 343. 

Connection Between Arthritic, Diathesis aud Tuber- 
culosis, 230. 
Diphtheria and its Relations, 898. 
Diphtheria, Therapy of, 509. 
Ectopic Pregnancy, The Practical View of, 787. 
Ether Versus Chloroform as an Anaesthetic, 69. 
Functions of the Peritoneum, 862. 
Gonorrhoea, Rectal, 229. 
Insanity and Criminal Responsibility, 303. 
Making Repairs, 822. 

Medical Legislation in Pennsylvania, 1010. 
Mercury — Effect of on Blood of Syphilities, 29. 
Prophylaxis of Puerperal Fever, 105. 
Some Signs of the Times, 980. 
Symphysiatomy, 673. 
Therapy of Abortion, 143. 

Traumative Surgery, Application of Cold in, 144. 
Typhoid Fever, The Hydriatrie Treatment of, 938 



Ulcers of the Legs, 983. 

Vaginal Exterpation of the Uterus, 2 72. 

Educational Need, An, Price, 707. 

Effect — of Bitters on Gastric Movements, 299. 

Of Diseases of the Ears upon the General Condi- 
tion, Cheatham, 256. 

Of Posture in Health and Symmetry, 874. 
Eggio, 79. 
Eichler, A, 53. 

Elastic Constriction as a Haemostatic, Measure, 901. 
Elbow, Saw-wound of, Cartledge, 652. 
Electrical execution, Rockwell, 89. 

Electricity— In Chronic Affections of Middle Ear, 429 

In Pelvic Troubles, 638. 

And Filled Teeth, 77. 
Electro-Endoscope, Improvement in, 195. 
Electrolysis in Treatment for Destruction of Superflu- 
ous Hairs, Bloom, 454. 
Electro-Therapeutics and Suggestion, 308. 
Eleventh International Medical Congress, 834. 
Ellis, P. F., 1042. 
Emergencies, Medical, 632. 
Empyema, 545, 1018. 

Treatment of, Steel, 994. 
Endometritis— Electrical Treatment of, 237. 

In Acute General Disease, 315. 
Enteric F«ver, 630. 

The Specific Treatment of, 941. 
Entropion, Double Congenital, 34. 
Epicystomy, 355. 

Epididgmitis — Dry Poultice in Treatment of, 108. 

With Simple Bandage, 393. 
Epilepsy, 429. 

What Can we Expect, 343. 

Borate of Ioda in, 573. 

Etiology of, 676. 

Mistaken Uraemic Convulsions, 701. 
Epileptics in Resembling Workers Cramp, 711. 

Post-paroxysmal Albuminuria in, 431. 
Epileptiform Attacks from Taenia, 357. 
Epilepsia Procursiva, 591. 
Epithelioma, 517. 

Of Jaw, Injury to Skull, etc., 960. 
Epistaxis, Hamilton, 585. 
Ergot— Abuse of in First Stage of Labor, 436. 

Medical Use of, Miller, 875. 

Effect of. 872. 
Ergotinim, 386. 
Erysipelas, 937. 

Luecke's Treatment of, 630. 

Recurrent, 34. 
Essensial Paroxysmal, Tachy Cardia, 33. 
Eucalyptus, Poisonous Symptoms, 944. 
Eucolyptol, By Intubation in Pulmonary Phthisis, 

830. 
Europhen, 904. 

In Surgical Dressing, 195. 

In Gynaecological Practice, 393. 
Evans, James, 925, 
Evans, Seth, 532. 
Evil Literature, 1028. 
Exalgine, 442. 

Observation on, 469. 

Poisoning, 232. 
Examination of Genital Tract directly after Labor, 

The importance of, 872. 
Exema Venous Varaix, with treatment, Stimson, 298. 
Exodyne, 80. 

Exophthalmic Goitre — Strophantus in, .187. 
Pathological Anatomy of, 17. 

Exophthalmos In Infant, 477. 

Extra-uterine Foetus. Removal of, 68. 

Extensive Hematocele, Resulting from Tubal Preg- 
nancy Rupturing with the Broad Ligament, 
Haggard, 881. 

Extirpation of both Testicles, Nervous and Mental 
Disturbances following, 23. 

Eyes, Care of the, 945. 



vi 



Index. 



Eye, Affections in Malaria, 11. 
Eye-lids, Phthiriasis of, 545. 

Faecis, Retained, 982. 

Facial Paralysis, Disturbance in, 113. 

Fallopian Tube, Lipoma and Fibroma of, 518. 

Farnsworth, P. J., 377. 

Fecal Vomiting and Neuroses, 516. 

Fell, George E., 605. 

Fever in Recently Delivered Women, 1026. 
Fibroids, Uterine, 706. 
Filtering Apparatus, New Departure in, 39. 
Fistula-in-Ano, 709; Adler, 450. 

Flat Foot, Etiology, Pathology and Treatment of, 
Phelps, 1041. 

Fluorescence of Quinine Concealed by Phenacetin, 199. 
Food, Disinfecting, 553. 
Folk Medicine in Russia, 557. 

Forced Respiration, per face mask, and Tracheotomy 

in Diphtheria, Fell, 605. 
Fracture — Lower Jaw of, Stimson, 17. 

Of Skull, Compound Depressed, 473. 

Of Base of Skull, 549. 

Of the Skull, 355. 
Freeman, Leonard, 534. 
Freghan, 175. 
Fruit Eating, 328. 
Functional Nitral Disorder, 234, 

Functions of the Stomach, The Effects of Acids on, 
948. 

Formulae 

Abdominal Wounds, Dressing for, 302. 
Acute Conyza, 25. 
Alopecia, 104. 
Amenorrhoea, 228. 
Anal Fissure., 418. 

Anaesthetic Salve for Hemorrhoids, 1011. 
Analgesic Mixture, 141. 
Anodyne Liniment, 67. 
Antiseptic — Formula, 944. 

Mouth Wash, 786. 

Powder, Improved, 786. 

Treatment of Profuse Diarrhoeas, 382. 
Arabian Balsam, 26. 
Aromative Laxative Essence, 416. 
Asthma, 704. 

Cardiac, 988. 

Combined with Digestive Disturbances, 271. 

Paroxysm of, 68. 

Treatment of, 67. 
Atrophic Nasal Catarrh, 341. 
Balanitis and Balano Posthitis, 26. 
Baldness, 988. 
Bronchitis— Acute, 988. 

In Children, 26. 
Burns. 382. 

Of the Eyes, 1029. 
Cascara Sarada, Elixir of, 468. 
Cerebral Sclerosis, of Specific Origin, 146. 
Cervical Cystitis in Woman, Pomade for, 67. 
Chapped Hands, 627. 
Chlora Anaemia, 93. 

Chlor-Hydrates of Ammonium, Therapeutic uses 
of, 142. 

Chloratic Dysmenorrhoea, 141. 
Cigarettes, Blant's Asthma, 464. 
Coccydynia, 790. 
Cod Liver Oil Emulsion, 786. 
Colds in Head, 1001. 
Constipation, 672, 171. 
Corzza, 188. 
Coryza, Acute, 988. 
Cough Mixture, 744. 
Creasote Syrup, 331. 
Cystitis in Women, 417. 
Burns, 744. 
Dandruff, 67. 



Debility from La Grippe, 275. 
Depilatory Powder, 337. 
Diabetes, 68. 
Diarrhoea — Summer, 540. 

With Intestinal Fermentation, 786. 
Digitalin in Cardiac Dyspnoea, 381. 
Diphtheria — Treatment of in Paris, 26. 

Creolin-Pearson in. 586. 

Treatment, 1029. 
Dipsonaria, 786. 
Disinfectant Mixture, 540. 
Dyspepsia, 67. 

Pyloric Pain in, 642. 
Earache, 188. 
Eczema of Scalp, 68, 
Embalming Fluid, 672. 
Excoriations, in Infants, 784. 
Epileptic Insomnia, 540. 
Eva Antiseptique de Pagliari. 
Exopththalmic Goitre, 831. 
Fissures of the Tongue, 959. 
Flatulence, Intestinal, 464. 
Frost Bites, Treatment, 831. 

Fuch's Coelyrium for Chronic Conjunctivitis, 726. 

Gleet, Injection for, 26. 

Glycerin Suppositories, 704, 744. 

Goitre, Exophthalmic, 627. 

Gonorrhoenal Erections, 786. 

Gonorrhoea, Antiseptic, Treatment of, 831. 

Heart Pains, 26. 

Hemorrhoids, 342. 

Ointment for, 67. 

Nutmegs in, 188. 
Hepatic Colic, 417. 
Hoarseness, 188. 
Hyperidrosis, 104. 
Ichthyol. 

Icterus — Turpentine In, 25. 
Ileo-Colitis, 418. 
Injection, Purgative, 68. 
Intestinal Antisepsis, 464. 
Intestinal Catarrhs of Children, 464. 
Itching, Menthol in, 418. 

In Scarlet Fever, 1021. 
Laryngeal Phithisis, 188. 
Lemonade for Diarrhoea, 613. 
Leucorrhoea, 507, 586. 
Loomis Lonic, 67. 

Lupus of the Nasal Mucous Membrane, 586. 
Menorrhagia, 582. 
Mercurial Stomatitis, 540. 
Morphine-V aseline, 607. 

Solution of, 341, 
Mouth Wash, 959. 
Oil of Turpentine, 341. 
Opiates, Substitute for, 302. 
Ozoena, Injection, 68. 
Painful Gums in Children, 226. 
Pasta Cerata, 342. 

Permanent Syrup of Hydraodic Acid, 382. 
Phenate of Cocaine, 228. 

Phthisis, Cyanide of Gold in Treatment of, 67. 
Pill Excipient. 381. 
Pneumonitis, First Stage of, 584. 
Pruritis, 142. 

Pruritus Ani, 573, 988, 68. 

Ani et Vulva, 605. 

Vulvae, 421. 
Resolvent Glycerole, 341. 
B,esorcin, Uses of, 188. 
Rheumatism, Articular, Acute, 228. 
Rheumatic Bronchitis, 672. 
Rhinitis Chronic, 786. 
Sick Headache, 381. 
Soft Goitre, 704. 

Special Tonic, Bellevue Hospital, 67. 
Spina Bifida Occulta, Bowen, 225. 
Spiritus Ophthalmicus, 210. 
Stimulant in Pulmonary Consumption, 744. 



Index. 



vii 



" Sun" Cholera Cure, 744. 

Suppositorus of Morphine Cocaine in Peritonitis, 

188. 
Syphilis, 188. 

Naso Pharyngeal and Laryngeal, 464. 
Tape-worm, Treatment of by Male Fern, 141. 
Terevene, Test of Purity of, 399. 
Tincture of Ginger and Podophyllum, 418. 
Tonsillitis, 67. 

Tonsils, Hypertrophy of, 672. 
Toothache, 672. 
Traumatic; Tetanus, 672. 
Truss. Dusting Powder, 342. 
Tuberculosis, Surgical, 540. 
Turpentine, Oil as a Deodorant, 943. 
Ulcerated Chilblains, 381. 
Uterine Haemorrhage, 228. 
Vaginal Injections, 417. 

Antiseptic Solution for, 25. 
Whooping Cough, 342. 

Inhalation in, 744. 

Galen's Hymn to the Creator, 200. 
Garments Ready made. Dangers of, 552. 
Gastric-Ulcers, Resorein Value of in, 572. 

Ulcers, Resorein in, 387. 
Gastro-Enteritis, Mercurial, 75. 

Gastro-Intestinal Cancer, Surgical Treatment of, 418. 
Germicidal Chemicals, Relation Value of, 478. 
Girson, Geo. Homer, 297. 
Gilliam, D. Todd, 94. 

Glass blowers, Dilatation of Cheeks in, 472. 
Flaucoma, Operation Treatment of 276. 
Glottis, Dilatation of in Laryngismus Stridulus, 75. 
Glycerine — In High Doses, 349. 

Suppositories with Boric Acid, 148. 
Glycosuric, or True Tabes, 392. 
Goalards Extract, Substitute for, 477. 
Goggans, James A., 179. 
Goitre — Cured by Galvanism, 987. 

(Exophthalmic), 390. 

Interstitial Iodine Injections in, 388. 
Gonococcus in Pure Culture, 352. 
Gonorrhoea, 734. 

Latent, 637. 
Gonorrhoeal — Arthritis, 804. 

Crystitis, so-called, 112. 

Cystitis, 547. 

Infection for Women, Results of, 754. 

Rheumatism, 753. 

Rheumatism in Infant, 278. 

Rheumatism, Phenacetin in, 73. 
Good Bedside Manners, 834. 
Granular — Conjunctivitis, 354. 

Lips, Treatment of, 76. 
Granular Inflammation of Conjunctiva. 428. 
Grattan, Nicholas, 882. 
Grattan, Pro essor, 844. 
Groff, John W., 1000. 
Grube, R. H., 648. 

Gynaecology, Object Lessons, Link, 797, 719. 

Haemorrhoids, 635. 

Treatment of, Deaver, 91, 962. 

Calomel in, 573, 193. 
Haemorrhages into the Labyrinth, 428. 
Haemorrhage at the Commencement of Pregnancy, 356. 
Haemorrhage — Post-partum, 476. 

From Nitact Skin, 947. 

After Tonsillotomy, 416. 

Following the Extraction of Teeth, 868. 
Haggard, W. D. 
Hair, The Care of the, 755 
Hamilton, J. K ,585. 
Hands, Chapped, for, 104. 
Hankin, E. H., 559. 
Happel, T. J., 403. 
Harsha, W. M., 996. 



Harris, Robert P., 608. 
Hay Asthma, 753. 

Head Injnry from Drunkenness, The Diagnosis of, 792. 
Headache — Frontal, and Iodide of Potash, 152. 

Relief of, 372. 
Heart — Hypertrophy and Dilatation of, 591. 

Murmurs, Non-Valvular, 425. 
Heat — In Fever, Production of, 471. 

Pathological Effects of, 715. 
Hemiphlegia after Diphtheria, 471. 
Hepatic Colic, Glycerine in, 73, 543. 
Hepatitio Parenchymatosa Benigna, 113. 
Hereditary Infection, 622. 
Hermaphrodism, 311. 
Hernia, 474. 

Schawlbe, Treatment of, 633. 

Of Abdominal Cicatrix after Laparotomy, 713. 

Radical Cure of Abdominal, 906. 

Radical Cure in Infants, 1021. 

Of Large Intestine, 76. 

Treatment of Strangulated, 826. 

Dangers of Manipulative of Treatment of Strangu- 
lated, Bennett, 481. 

Ventral, Gilliam, 94. 

Harsha, 996 
Hespus Zoster, 352. 

In Children, 316. 
Hiccough, 302. 
Hiccough, Buchannon, 468. 
Hiccough — Incessant 912. 

Obstinate, The Treatment of, 736. 

Obstinate, 308. 

And Compression of the Phrenic, 310. 
Histerical Concomitants of Organic Nervous Disease, 

Hughes, 138. 
Hirst, Barton Cooke, 653. 
Hip-joint — Congenital Dislocation of, 592. 

Disease, Lateral Fraction Splints for, 391. 
Hobbs, Arthur G., 639. 

HafFkines Method of Protective Inoculation against 

Cholera, Hankin, 559. 
Hovent, Dr., 878. 

Hot Springs, Doctors and Toutors, 280. 

Hot Water Bottles, Disadvantages of, 108. 

Hughes, C. H., 138. 

Hyde, 0. A., 20. 

Hydrargyrum Lactatum, 320. 

Hydrocele, Radical Treatment of, 900. 

Hydrogen Peroxide in Mixtures, 422. 

Hypodermic Injections in Children, 357. 

Hypertrophic Hepatic Chirrhosis, Freghan, 175. 

Hypertrophied Tonsils, 496. 

Hypogastric Nerve Section and the Bladder, 312. 

Hypnotics, Ensley, 262. 

Hypnotism — In the Psychosis, 425. 

Training by, 558. 
Hysterectomy, 7L4. 
Hysteria — In Children, 159. 

Clinical Notes of, In Boy Eight Years of Age, 
Ayres, 18. 

And Fiscal Impaction in a Neurotic Child, 
Stockton, 87- 
Hysterical Fever, 465. 
Hysteropecy, 196. 

Ice — Manufacture of, 5. 

In Dysentery, 830. 
Ichthyol — In Diseases of Women, 37. 

In Sore Nipples, 97. 
Idiopathine, 716. 

Impacted Cerumen and its Results, Report of case of, 
785. 

Inebriety — Treatment of, 388. 

Strychnine in, 476. 

Diseases of, 1027. 
Infants — Artificial Feeding of, 21. 

Feeding, 945. 

Insomonia in, 551. 

Infants Washed after Birth. 636. 



viii 



Index. 



Infantile — Diarrhoeas, Salicylate of Bismuth, 437. 

Paralysis, Treatment, 949. 

Paralysis, Brower, 95. 

Respiratory Spasm, 1014. 
Infective Enteritis, 390. 
Infectiousness, Periods of, 432. 

Infectious Multipal Neuritis following Facial Erysipe- 
las, 305. 

Inferior Maxillary Nerve, Resection of, 180. 
Influenza — Alkalies for, 109. 

In Berlin, 151. 

Colombo in, 148. 

And Drugs, 280. 

Wave in Egvpt, 49. 

Effect of on Middle Ear, 391. 
Ingals, E. Fletcher, 11, 210. . 
Inguinal Hernia, 397. 

Old Right, Irreducible, Operation for, Crandall, 
56. 

Insane — Anomalies of Crania of the, 632. 

Narcolepsy in, 310. 
Insanity, Origin of, 869. 
Insomnia, The Treatment of, 832. 
Intermittent Fever, High Temperature in, 276. 
Internal Antisepsis, 466. 

International Dermatological Congress in Vienna, 40. 
Interstitial Keratitis, Mercurial Ointment in, 494. 
Intestine, Congenital Obliteration of Small, 433. 
Intestinal — Anastomosis and Suturing, 593. 
Intestinal Obstruction, Wiley, 840. 

Treatment of Post-Operation, 35. 

Due to Misplacement of Uterus, 397. 

From Gall Stone, 235. 
Occulsion, Use of Constant Electric Current in, 
402. 

Intensity of Heart Sounds, increasing, 356. 

Intra-Mammary Abscesses, 312. 

Intra Nasal— Tube, An, 948. 

Obstruction, Effect of, Cline, 259. 

Intubation, A Substitute for, 826. 

Ihturbation and Tracheotomy in Cases, 158. 

Intus Susception, The Operative of, 750. 

Investigations in the Haemoglobin percentage, and the 
Estimation of the Red Blood Corpuscles in the last 
period of Pregnancy and in the Peurperal State, 
313. 

Iodine, Compound Elixir of, 434. 
Iodide of Cyanogen, 399. 
Iodoform, 743. 

Dermatitis, 351. 

Cause Adulterated, 479. 
lodism, Severe Accident of, 748. 
Iris, Tuberculosis of, 392. 
Iron, Toxications of, 307. 

Ischio, Rectal Abscess and Fistula in Ano- Treatment 

of, Wharton, 965. 
Isolated Hernia and Strangulation of the Appendix 
Vermiforms, 1024. 
- Itch, Salicylated Collodion for, 150. 
Iturbation for Stenocis of Tubercular Laryngitis, 394. 

Jackson, Edward, 655, 295. 
Jewell, P. M., 409. 

Keeley Cure, 586. 
Kelly, Howard A., 241. 
Kellogg, E. W„ 57. 

Kaloid of the Male Urethra, Minges, 329. 
Kidney, Cystic Disease of, 111. 
Knee — Jerk, 193. 

Tuberculous Disease, 147. 
Kramer, S. P., 536. 
Kcfinig, Adolnh, 334. 
Korte, W., 283, 321, 247,201. 

Labium, Cancer of, 1026. 

Lacerations of Perinaeum, Prevention of, 712. 



Lachrymal — Obstruction, 550. 

Sac, Curetting of, 548. 
Lacquer Poisoning and Notes, Ross, 5t>9. 
Larrabe, Jno. A., 703. 
Larynx — Exterpation of, 235. 

Intubation of, 635, 1013. 
Laryngeal Papilloma, Exterpation of, 398. 
Lavage in Chronic Gastric Disease, 346. 
Law, French Medical, 597. 
Lay, F. H., 408. 
Lehlbach, Chas. F. J., 372. 
Leonard, P. I., 135. 
Leonhardi, F., 844. 
Levoisne, 240. 
La Grippe, 31. 
Lanphear, Emory, 564, 843. 
Laparotomies — By R. Stansbury, Rodgers, 253. 

In Allegheny General Hospital by R. Stansbury, 
Sutton, Rodgers, 50. 
Laboratory Device, 359. 
Labor Pains, Vinum Ipecacuanhae in, 569. 
Nolte, Lewis G., 946. 
Ligamentum Patellae, Elongation of, 154. 
Lightning, Injury by, 583. 
Limits of the Art of Healing, Nothnagel, 161. 
Link, W. H., 797, 719. 
Lister, Sir Joseph, 556. 
Lithium Nitride, 80. 

Lithotomy, Relation, Value of Perineal and Supra- 
Pubic, 156. 
Liver Indigestion, Myers, 721. 
Living Animals, Experiments on, 359. 
Locomotor Ataxia, 309. 
Losophan, 904. 

Louisville Medico-Chirurgical Society, 1001. 
Low Temperature and Phthisis, 298. 
Lupus Enythematosus of Eyelids and Face, Treat- 
ment of, 67. 

Lupus Vulgaris, General Infections Complication, 86. 

Luxion, Ancient, 433. 

Lydston G. Frank, 169, 757. 

Lye, Disinfecting Power of, 553. 

Lymphosarcoma, Arsnic in, 543. 

Lysol, 453. 



Macerated Foetus on Child-bed, Influence of, 517. 
Male Fern Toxicity, 381. 
Malignant — Neoplasms, 313. 

Tumors, Methyl Violet in, 630. 
Manly, Thomas H., M. D., 913. 
Mann, M. D., 401. 
Mansfield, Arthur D., 800. 

Marriage Question from Standpoint of Gynaecology, 

Simpson, 492. 
Massage, 833. 
Massey, G. Betton, 571. 
Mastoid, Process, Opening of, 184. 
McKalway, George I., 602. 
Meats, Roast and Baked, 428. 

Mechanical Treatment of Trachoma, Jackson, 295. 
Medicated Inhalations, Effects of, 866. 
Medical Expert Testimony, Evils of, 558. 
Medical Legislation, 807. 
Medication of the Future, Koenig, 334. 
Melanosis, Infantile, 197. 

Melanotic Sarcoma; Vesical Calculus; Cold Abscess 
of Hand; Fracture of Femur Rupture of Indriceps 
Tendon, Park, 281. 

Memorizing Doses, 943. 

Menstruation, precocious, 157. 

Metatastic Phlegmon, Histology of, 283. 

Methylene Blue, Therapeutic Uses of, 147. 

Metrorrhegia, 357. 

Treatment of, 795. 

Meynert, Prof, Death of, 200. 

Microbicide Substances of the Serum, 118. 

Migraine, 389. 

Treatment of, 628. 



Index. 



ix 



Milk — Analysis, Method of, 359. 

Determining Fat in, 554. 

Innunity Produced by, 596. 

Futritive Value of, 79. 

Sugar in Milk, 319. 

Tubercle Bacilli in, 239. 
Miller, Katherine, 875. 
Minges, George, 329. 
Mind, Influence of on Body. 1020. 
Mole, Hydatiform, 712. 
Moore, Pappe, 156. 
Moral Side, the, 556. 
Morphine and Atropine, 148. 
Morphinism, 423. 

In Relation to Sexual Functions and Appetite, 
and Effect on Offspring of Users of the Drug, 
Happel, 403. 

Morphology of Breast Milk and the Nutrition of the 
Child, 1025. 

Motive, Preparation and Results in Abdominal and 

Pelvic Snrgery, Price, 1031. 
Mouldy R,ice, Poisonous Nature of, 199. 
Movable Kidney and Hydronephrosis, 351. 
Munford, S. B., 261. 

Mutilations, Hereditary Transmission of, 597. 
Myers, WiJliam H., 998. 

Myxoma of the Nose and Fibro Myxoma of Nasal 

Pharynx, Dabney, 645. 
Nasal Catarrh, 911. 

Nasal Obstructions and Deformities, Conservative Sur- 
gery for, 750. 

Nasal Passages During Childbirth, The care of, 784. 

National Bacteriological Institute, 716. 

Nerves, Blood-vessels of, 431. 

Neuralgia, 869. 

Neuralgia, Facial, 72. 

Neuralgia of the Toe, 793. 

Neurasthenia, 308. 

Varicocele, Relatio'n to, 516. 

And Hyper-Acidity, 112. 
Neurosis — An Unusual, 151. 

Vesication of Fourth and Fifth Dorsal Vertebrae 
in, 5 4. 
Nutrition, Enema, 318. 
Nitrate of Silver, Stains, To Remove, 408. 

Use of in Urethral Inflammation, 1023. 
Norbury, Frank Parsons, 365, 686. 
Nose, Operations on the, 832. 
Notes, 749. 
Nothnagel H., 161. 

Nunclear Ophthalmoplegia in the Course of, Tabes, 

Rendu, 121. 
Nutritive Enema, The Test, 869. 
Nystagmus in Affections of the Ear, 145. 
Nystagums, Miners', 390. 



Obstetrics, Narcosis in, 754. 

Obstetric Forcepe, Proper Method of Applying, 794. 
Official Lists. 

Official List of Changes of Officers of U. S. Marine Hos- 
pital Service, 718, 1030. 

Official Changes of Medical Officers U. S. Marine Hos- 
pital, 598. 

Official Lists of Changes in United States Army 
Medical Department, December, 4-10. 990 

Official Lists of Changes in the Station and Duties of 
Officers serving in the Medical Department United 
States Army, from November 27 to December 3, 
'92. 952. 

Official List of Changes in United States Army, Medical 
Department from November 20, '92 to November 26, 
92, 912. 

Official Changes in United States Army, Medical De- 
partment from November 13 to November 19, 1892, 
874. 



Official Lists of Changes in United States Army Medi- 
cal Department from November 6 to November 
12, 1892, 834. 

Official List of Changes in United States Army Medi- 
cal Departmeni October 30 to November 5, 1892 
796. 

Official List of Changes in United States Army Medical 
Department October 23 to 29, 1892, 766. 

Official List of Changes in Medical Department United 
States Army, 687. 

Official List of Changes in Medical Department United 
States Army, 717. 

Official List of Changes of Officers in Medical Depart- 
ment United States Army, 638, 1029. 

Obstetrical Society of Philadelphia, 678. 

Official Changes in Medical Department, Uuited States 
• Army, 598. 

Railway Surgeons, Sixth Annual Meeting, 990. 
Ointments, 417. 

Old Age, Pathology of, Grube, 648. 
Olshausen, Rob't., 1000. 

Operation for Cleft of the Hard and the Soft Palate, by 

Dr. B.W. Whitehead, Gibson, 297. 
Operative Treatment of Retro-displacement of Uterus, 

274. 

Ophthalmia Neonatorum, Veasey, 6. 
Ophthalmia Neonatorum, The Prevention of, 786. 
Opium in Melancholic States, 469. 
Orchitis following Influenza, 546. 
Os-Calcis and Astragalus, Resection of, 142. 
Osier William, 537. 

Osteo-Arthropathy of Pulmonary Origin, 430. 
Osteo-clasis, Geattan, 882, 844. 
Oubaine, 26. 

Ovarian Pregnancy, A Case of — Laparotomy — Cure, 

Lanphear, 843. 
Ovaries and Tubes, Resection of, 77. 
Ovary — Compensatory Hypertrophy of, 357. 

Endothelioma of, 197. 
Oxygen — Inhalations, 306. 

Inhalation of, in Obstetrics, 396. 
Ozone, Action of on Organism, 146. 



Painful Incident, 834. 

Paracentesis Pericardii in Graves' Disease, 276. 
Paradoxical, 199. 

Paraffinic Nitrates, Action of on Blood Pressure, 31. 
Paralysis — Agitans, 391, 393. 

Of Brachial, Musculo-Cutaneous Nerve, 631. 

Of the Insane, 227. 

Disease of Spinal Cord in, 710. 
Paralytic Obstruction of Intestine, 427. 
Paralyzed, Associated and Substitutive Movements in 

the, 591. 

Paraplegia of Syphilitic Origin, 685. 

Parasitic Foetus, 236. 

Park, Roswell Prof., 281, 523, 960. 

Pathi-Fracture and Lesions of the Soft Parts which 

involve the Ankle Joint, The Treatment of, 

Manly, 913. 

Pelvic — Contraction, Porro's Operation for, 237. 

Diseases on the Voice, Influence of, 277. 

Inflammations, The Natural History of, 738. 

Inflammation, Salpingitis and Peritonitis; Uterine 
Displacement, Man, 401. 

Pain, Salicine for, 518. 

Surgery, Experience in, Brokaw, 922. 
Pental as an Anaesthetic, 31. 
Pepsin and Allied Preparations, Currier, 421. 
Perchloride of Iron in Paralysis of the Bladder, 1016. 
Peritonitis, Chronic in Children, 38. 
Perityphlitis, Treatment of, 20. 
Perforative Aortitis, 429. 
Pericarditis, 474. 
Perineum, Protection of, 517. 
Periodical Intermenstrual Pain, 370. 



X 



Index. 



Peritoneal — Cavity — Transfusion of Salt Solution of, 
108. 

Adhesions after Ovariotomy, 755. 
Periostitis, Albuminous, 152. 
Peritonitis, Surgical Treatment of, 742. 
Perkins, C. E., 92. 

Peroxide of Hydrogen in Intestinal Diseases, 944. 

Pessary, Worn Thirteen Years, 237. 

Pes Valus Paralyticus, 634. 

Peter, Robert, 221 . 

Pharynx, Benign Ulcers of, 592. 

Phelps, A. M., 46. 

Phelps, A. M., M. D., 1041. 

Dr. Phelp's Misquotes Dr. Sayre, 346. 

Phenacetine, 829. 

The local use of, 828, 905. 
Phenocoll — In the Treatment of Malaria, 907. 

And Piperazine, 907. 
Pharmacy and Doctors of, 240. 
Phocomelous, Infant, 77. 
Phosphorous — Antidote to, 140. 

Poisoning, Permagnate of Potassium in, 536. 
Phthisis, A New Treatment, 752. 
Phylantin, 119. 

Physician on the Witness Stand, 951. 
Pigmentation of the Skin, 413. 
Pilocarpine — Poisoning by, 149. 

In Dermatology, 286. 
Piperazin, 147, 387, 349. 
Pleurisy, 350, 543. 

With Effusion, Anders, 361. 
Pleuritic Effusions, 275, 542. 
Pneumonia, 516, 670, 

With Digitalis, 544. 

Lencocytosis in, 154. 
Pneumococci in the pus, 357. 
Poisons, Antidotes for, 867. 
Polyuria and Sciatica, 152. 
Pons, Tumor of, 114. 

Population Question and Symphyseotomy, 710. 

Porencephalon, 394. 

Pott's Disease. Abscesses in, 517. 

Practical points in Therapeutics Larrabe, 903. 

Pregnancies, Extrauterine, 236. 

Pregnancy — Hemichorea in, 157. 

Perineorrhaphy During, 115. 

In an Ovarian Sac, 949. 

And Ovarian Tumor, 595. 

And Ventro-Fixation, 277. 
Preparing the Field of Operation; Circumcision, In- 
testinal Obstruction, Appendicitis; Dawbarn, 207. 
Presbyterian Hospital, Feng Chow Fu, China,Coltman, 
Jr., 441. 

Prescription for Young Physicians, 811. 
Presentation, Repeatedly Changed, 157. 
Price, Joseph, 521, 707, 1031. 
Prickly Heat, 472. 
Prince, A. E., 584. 

Principle Returned with Interest, 726. 
Prize, Samuel D. Gross, 912. 

Professorship of Pathological Anatomy Fund, S. D. 
Gross. 

Professorship in the Jefferson Medical College, A new, 
940. 

Progressive— General Paralysis, 389. 

Progressive Muscular Atrophy; Headache from Eye 

Strain; Hysterical Vomiting; Dance, 126. 
Prolapse of Extremities in Head Presentation, 169. 
Prophylaxis of Scarlatinal Nephritis, 38. 
Proprietary Medecins, against, 280. 
Prostate, Monsterous Hypertrophy of, 632. 
Prostatic Hypertrophy, Massey, 571. 
Prostatectomy, 236, 1024. 
Prostatitis, A Cause of, 806. 
Pruritus Ani Pryor, 568. 
Pryor, J. E., 568. 
Pyrexia in Uraemia 128. 
Pseudo Tabes 234. 

Psychical Disturbances, Relation'of Pelvic Disease to, 
\ ,585. 



Public Duty of Physicians, 950. 
Puerpeal Systic Infection, 671. 
Pulmonary Gangrene, 426. 

Pulse, Respiration and Temperature of Children, 545. 
Purpura Fulninans in Children, Dercum, 835. 
Purifying Water, 834. 

Purpura of Mucus Membrane of Mouth, 234. 
Purulent — Cavities and Fistula?, Peroxide of Hydrogen 
in, 425. 

Opthalmia Nesnatosum, Prevention of, as Cause 

of Blindness, 258. 
Pleurisy, 544. 
Pyogenic Affections, by Production of Artificial Ab- 
scesses, 582. 
Pyorrhea Alveolaris, 751. 
Pyrazole, 629 

Pyrexia and Antipyrexia, 113. 
Quacks, 789. 

Qualitative Tests for Sugar in Urine, Riker, 443. 
Quinine — Nervous Symptoms following, 149. 
As a Parturifacient, 872. 

Rabies — Immunity and Treatment by Blood Serum, 
437. 

By Intravenous Modification of Pasteur's Method, 

523 

Railway Surgery at the Pan-American Medical Con- 
gress, 874. 
Raynaud's Disease, 546. 
Rectal Injections, 946. 

Music, 24. 
Recti Muscles, Superior, Spasm of, 589. 
Rectum — Syphilitic Ulceration of, 104. 
Syphilitic Stricture of, 355. 

Reflex Urethral and Genital Neurosis; Urethral 
neuralgia and Hyperaesthesia; Hyperaesthesia and 
Neuralgia of the Tests, Lydston, 169. 

Reichmann's Disease, 427, 

Riker, J. D., 443. 

Relation of the so-called Ninorgyn Ecological Opera- 
tions to Intra-Pelvic Inflammation, 737. 
Removal of Fragment of Bone from oesophagus through 

the Pharynx, Benedict, 573. 
Renal — Artery, Aneurism of, 474. 

Parenchyma, Partial Nephrectomy and Reunion 
of, 194. 
Rendu, 121. 

Reply from Dr. Phelps to Dr. Sayre of August 27th. 
Sayer, 514. 

Report of Two Cases of Nephrectomy— Recovery, 
Nolte, 956. 

Reproduction from Memory of Letter to Dr. Sayre, 

Phelps, A. M., 514. 
Resection of the Intestine with Circular, Enteror- 

rhaphy, Jewell, 409 
Respired air through the nose, Route of, 392. 
Retained Placenta, 637. 

Effect of atmospheric Pressure, 378. 
Retention Tumors, 740. 
Retina, Detached. 145. 

Spontaneous Cure, 894. 
Retinal Blood-vessels, 151. 
Retroflexion and Gastric Neurosis, 357. 
Rheumatism, 148. 

Acute Articular, Treatment of, Williams, 129. 

Cranberries in, 749. 
Rheumatoid Arthritis, 389. 
Rhinitis, Acute with Retention, Perkins, 92. 
Rickets in Australia, 38. 
Ringworm, Treatment of, 944. 
Robinson, Fred Byron, 608. 
Rockwell, A. D., 89. 

Rodent Ulcer, Confusion Between, and Epithelioma, 
152. 

Rodgers, Mark A., 50, 253. 
Ross, Alice MacLean, 569. 
Rules, etc., Southern Med. Col. Ass., 981. 



Index. 



xi 



Rupture of Biceps and Maternal Impressions, Currier, 
968. 

Ruptured Tubal Gestation, 476. 

Ruptured Tubal Pregnancy, 1027. 

Rush Medical College Appointments, 319. 

Salipyrin, 260. 
Saliva in Disease, 318. 
Solol — In Gonorrhoea, 829. 

Reaction of, 40. 

Spurious, 554. 
Salophen, 563, 906. 
Sayre, Louis A, 346, 514. 
Scalp, Contusions of, 704. 
Scalpel, the, 12j0. 
Scarlatinal Bubo, 25. 
Sciatica and Varicose Veins, 545. 
Science and Women, 828. 
Scoliosis, 335. 

Scorpion Sting, Aconite for, 109. 
Seborrhoea of the Scalp, A Treatment of, 830. 
Secondary Carcinoma of the Uterine Body, 316. 
Self-limited Disease, Treatment of, Black, 991. 
Sernral, 866. 
Sepsis, Peter, 221. 

Septicamia, Simulating Typhoid, 432. 
Sewage, Disposal of, 117. 
Sex, determination of, 76. 

Sexual Hypochendiusis and Perrasum of the Genesic 

Instinct, 946. 
Shaw, Charles S„ 21. 
Sheffer, J. M., 226. 

Shepperd's Purse, Hasmastative Value of, 631. 
Shock, Evans, 477, 924. 

Shurly, Gibbs Treatment of Tuberculosis, Ingalls, 210. 
Sick Room, Light in the, 871. 
Silver Nitrate in Gonorrhoeal Epididynritis, 830. 
Simpson, A. B. 492. 

Sinues of Face, Cells of Ethmoid, etc., Theory of, 499. 
Sjoquist Method, of Hydrochloric Acid in Gastric 

Juice, 345. 
Skin— Bony Deposits in, 155. 

Diseases, Treatment of, 791. 

Fatty Secretions of, 310. 

TVopho, Neurosis of, 88. 
Skulls, to Distinguish Male from Female, 623. 
Sleeplessness, 470. 
Slow Pulse, 111, 947. 

Slur on the Medical Profession of Chicago, 400. 
Snake Bite, Strychnia and the Treatment of, 941. 

Society Reports. 

Allegheny County Medical Society, 23, 337, 526, 658. 
County Medical Society, Philadelphia, 851. 
Clinical Society of Louisville, 931, 500. 
Crawford County Pa., Medical Society, I. M. Cooper, 
399. 

The Clinical Society of Louisville, 97. 729. 
Medico-Chirurgical Society of Louisville, 772, 816, 664. 
Medico-Chirurgical Society of Louisville, 299, 413, 1045. 
Mitchell, District Medical Society, 263. 
Mississippi Valley Medical Association, 199, 539. 
Milwaukee Medical Society, 184, 975. 
Obstetrical Society of Philadelphia, 574, 812, 969. 
Philadelphia County Medical Society, 973. 
Surgical Society of Louisville, 693, 614, 458. 
Southern Surgical and Gynecological Association, 887. 

Sodium Salicylate, Solution of, 160. 
Solution, Nature of, 160. 
Sore Nipples, Ellis, 1042. 
Sore Throat, Treatment of, 32. 
Spasmodic Torticollis, 311, 
Specialism, Price; 521. 

And the In?ane, Werner, 1038. 
Spitting, Stop, 198. 
Spleen, Enlargement of, 316. 
Sprains, 594. 
Stammering, 675. 



Stapes in Animals, Avulsion of, 351. 
Steele, D. A. K., 994 

Stenosis at the Aortic Orifice, Borland, 332. 
Sterility — In the Married, 436. 

In the Male, 979. 
Stimson, A. O., 17, 298. 
Stockton, Chas. G., 87. 

Stomach — Cardiac End of, Carcinoma of, 35. 

Disease, Solanine in, 470. 

Illumination of, 547, 

Ulcer and Cancer of, 36. 

Washings — Influence of on Assimilation, 74. 

Rupture of, Groff, 1000. 
Strange Medico-legal Case, 440. 
Strangury, Electrostatic of, 468. 
Status Epilepticus, Pilocarpine in, 108. 
Strychnine, 240. 

Stryone in Middle Ear — Suppuration, 424. 
Successful Surgery. Dunsmoor, 604. 
Suicide during Perturition, 360. 
Sulphonal, Buchanan, 884. 

Superior Maxilla and the Cheek, Extirpation of, 671. 
Suppuration — Due to Pneumococci, 111, 

Therapeutic Value of, 512. 
Surgery — Of the Gall-passages and Liver, Korte, 201, 

247, 283, 321. 

Surgical Interference in Cerebral Diseases in Children, 

Norbury, 365. 
Surgical Tuberculosis, Cinnamic Acid in, 246. 
Suturing of Divided Tendons, 949. 
Swain, Henry L., 287. 
Sweating Hands, Treatment for, 742. 
Swellings above the Clavicle, 342. 
Sycosis, 491. 

Symptomatic Value of Pulsations in Ear, 430. 
Symphysiotomy, Hirst, 653. 
Syphilis — Among Ancient Egyptians, 160. 
Cerebral, 631. 

Treatment of by Europhen, 306. 
And General Paralysis, 655. 
Proper Course, 110. 
Pre-historic, 360. 

Of Pharyngeal and Pre-epiglottic Tonsils, 384. 
Syphilitic — Disease of the Brain, Diagnosis and Prog- 
nosis of, 33. 

Infection, Sources of, 318. 
Infants, How to Raise, 436. 
Syringes for Subcutaneous Injection, 220. 

Tabes Dorsalis, Treatment of, 66. 
Tabes, Dorsalis, 331, 547. 

Tabes with Saccharine Diabetes, Association of, 430. 
Tangling of Umblical Cords, 396- 
Tannin, Reagent for, 80. 
Tape-worms, 627. 

Pumpkin Seed in Treatment of, 388. 
Torticollis, Treatment of, 364. 
Teal's Operation, A Modification of, 948. 
Telephone — Effects upon Hearing, 596. 
Temperature of the Aged, Normal, 35. 
Tendons, Union of Divided, 435. 
Tenia, Treatment of, 349. 
Tenotomy, 432. 

Testicles, Analgesia and Atrophy of, 153. 
Tetanus, 386, 622. 

Cu ed by Antitoxin, 675. 

Due to Puncture with Hypodermic Needle, 698. 
Teucrium Scordium in Pruritus Ani, 386. 
Therapy of Male Impotence, 423. 
Thread Worms, Treatment of, 192. 
Therapeusis of Piperazin. 905. 
Thigh, Amputation of, S27. 
Thiol — Antiseptic Reducing Agent, 90S. 

In Infantile Therapeutics, 906. 
Thiophen, 424. 
Thomson's Disease, 233. 

Thorax, Relation of Bronchi to Posterior Wall of, 516. 
Thrombosis of the Vulva, 314. 
Thymol, Dental Use of, 791. 



xii 



Index. 



Tic Donlonreux, 941. 

Tobacco — Influence of, on Vision, Dowling, 642. 

Smoke, Defence of, 38. 
Tongue— Surgery of, 676. 

Trichinosis of, 80. 
Tonics, Popular Delusions about, 866. 
Tonsilitis, Acute, Contagiousness of, 553. 
Tonsils, Emigration of Leucocytus from, 193. 
Too Many Physicians, 897. 
Toothache, 868 

Torsion of Arteries, On the, 739. 
Tower, Franklyn J., 181. 
Towler, S. S., 1001. 

Toxic and BactericideAction of Serum of the Blood of 

the Insane, 279. 
Toxic Medicaments, Safe Method, 120. 
Tracheotomy— Tube, 677. 

Statistics, 551. 
Trachoma— Treatment of, 114, 234. 
Tragus, Betractor, 313. 
Transverse Fractures of the Patella, 395. 
Translations, 667, 699, 779, 825, 864, 900, 939, 983, 1011. 
Traumatic Abscess of Liver and Perinephritic Space, 

Bryan, 331. 
Trephine, 548. 

Trephining for Epilepsy — Traumatic Ascending Neu- 
ritis, Park, 523. 
Trephining for Relief of Intra-Cranial Pressure, 1022.. 
Trichloride of Iodine in Ophthalmological Practice, 388 
Trional, 906. 

True Pathology of Sudden Death in Acute Pneumonia, 
and the best means of averting it, Lehlbach, 372. 

Tubal — Diseases, 595. 
Moles, 986. 

Tubes and Ovaries, Bemoval of, 634. 

Tubercle Bacillus from Mother to Foetus, Passage of, 
39. 

Tubercular Meningitis, Contribution to, 112. 
Tubercular Peritonitis, Treatment of, Myers, 998. 
Tuberculin in Babbits, Action of, 275. 
Tuberculosis — Cantharidinates in, 193. 
Congenital. 153. 

Danger of Counter-irritation in Localized, 73. 

Prize for Essay on, 440. 
Tuberculous Laryngitis, Intubation in, 748. 
Turnbull, Lawrence, 140. 
Twins, Unusual Case of, 277. 
Typhoid Fever, 78, 493. 

Blailock, 679. 

In Children, 945. 

Chloroform in, 468. 

Distetic Treatment of, 716. 

FelBovis in, 516. 

Milk Epidemic of, 159. 
Typho-Malarial Fever so-called, Young, 369. 

Ulcer of the Stomach, The Dietetic Treatment of, 756. 
Umbilical — Vegetations, 55. 
Umbicial Wound, Sepsis of, 187. 
Umbilicus in New-born Children, 356. 
Urethra — Besection and Suture of, 547, 

Sarcoma of, 429. 
Urinary Antisepsis, Microcidine in, 72. 



Urine — Antipyrin in Incontinence of, 146. 
Nucles, Albumine in, 150. 

Two Practical Suggestions for Analysis, Bishop,. 
652». 

Testing, Beagent Papers for, 554. 
Vesication in Incontinence of, 515. 
Urticaria Factitia, 429. 

Uterine — Haammorrhage, On Plugging the Cervix 
Uteri instead of Vagina in, 870. 
Inertia, Ipecacuanha in. 713. 
Mole, 397. 

Mucus Membrane. Beproductkm of, 37. 
Uteras — Complete Bupture of, 195. 
Extirpation for Cancer, 703. 
Fibroid, Tumors of, 158. 

In Peurperal State, Hydrastis Canadensis in, 476. 
Betroflexed and Incarcerated — Death, 477. 

Vaccination — Law in Italy, 119, 120. 

Statistics, 79. 
Vagina, Exploratory Incisions through, 277- 
Vaginal — Hysterectomy in Pelvic Suppuration, 715. 

Secretions, 314. 
Vaginismus, 1027. 

Valvular Lesions of the Heart, 1020. 
Varicocele, 658. 

Variola Disseminated Sclerosis in Convalescence, 591. 
Vaseline, Use of, 347. 
Veasey C. A., 6 . 

Vermiform Appendix, Bemoval of, 677. 
Veratrum Viride in Pneumonia, 1018. 
Vertigo, Varieties of, 751. 

Vinum Impecacuanhas in Weak Labor Pains, 873. 
Virchow on Sick Nurses, 557. 
Varility, Effects of Antiseptics on, 198. 
Vomiting — Hydrochloric Acid in Treatment of, 294. 

Of Pregnancy, Treatment of, 785. 

Belief of, 148. 

Treatment of, 793. 

Uncontrollable in Pregnant Women, 236. 
Vulvo-Vaginitis in Young Girls, 950. 

Water — Ukali and Bacteria in, 358. 
For Babies, 833. 

Purifying by Unburnt Lime, 438. 

Simple Tests for Impurities of, 795. 
Warren, A. E., 499. 
Werner, Marie B., 583, 1038. 
Webb, I. E., 1043. 
Wharton, Henry B., 965. 
What's the Matter ? Shaffer, 220. 

When shall we Trephine in Fractures of the Skull ? 

Lanphear, 564. 
Wiley, S. N., 840. 
Williams, D. H., 129. 
Winter Cough and Nose Obstruction, 603. 
Wilson, H. Augustus, 599. 
Woman's Place, 951. 

Wounds of the Brain and Their Beslts, Norbury, 686. 
Young, W.B., 369. 

Zinc Oxide in Hystero-Epilepsy, '830. 



Vol. X,XVII, No. I. 
Whole No. 1844. 



JULY 2, 1892 



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CLINICAL LECTURES. 

Robert Olshausen, M. D., Berlin, Germany. 
Eclampsia 



C. A. Veasey, M. D., Philadelphia, Pa. 
Ophthalmia Neonatorum 



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THE 

MEDICAL AND SURGICAL 
REPORTER. 

No. 1844. PHILADELPHIA, JULY 2, 1892. Vol. LXVII— No. 1. 



Clinical Hectares* 



ECLAMPSIA.* 



By DR. ROBERT OLSHAUSEN, 

BERLIN, GERMANY. 



Gentlemen: — Eclampsia is a disease 
which for a long time past has commanded 
great interest from physicians ; its obscure 
origin being by no means the smallest 
cause for such being the case. 

An elucidation of its aetiology, in all 
probability, will not be by means of clini- 
cal research, but rather through experi- 
mental methods or chemical examinations 
of the blood and secretions. Nevertheless, 
it will be necessary for any theory of the 
genesis of the disease not to clash with its 
clinical manifestations, but, rather in the 
principal points at least, to coincide with 
them. 

I have at hand the histories of two hun- 
dred cases of eclampsia, occurring between 
September 1st, 1885, and April 17th, 1891, 
at the Royal University's Women's Clinic 
here in Berlin. After a revision of the 
clinical manifestations observed in these 
cases, I will review comparatively the pres- 
ent theories regarding the genesis of the 
disease. 

The two hundred cases upon which I 
base my observations and conclusions oc- 
curred during 2,054 days. This would 
mean one case in every ten and one-third 
days, or on an average of three cases in 
one month. 

It has been frequently observed that 
cases of eclampsia occur in "bunches," 
and the following table will elucidate this. 
They occurred as follows : 

In 1886, from July 22 to August 15, or 
in 25 days, 7 cases; from Sept. 12 to Sept. 

* Delivered in part before the Berlin Medical 
Society, December, 1891. Translated from Volk- 
manns Collection of Clinical Lectures. 



25, or in 14 days, 5 cases. In 1888, from 
Oct. 8 to Oct. 23, or in 16 days, 7 cases; 
from Nov. 22 to Dec. 28, or in 37 days, 
8 cases. In 1889, from Jan. 4 to Jan. 18, 
or in 15 days, 6 cases; from Dec. 5 to 
Dec. 31, or in 27 days, 8 cases. In 1890, 
from Feb. 4 to Feb. 28, or in 25 days, 6 
cases; from June 22 to July 2, or in 11 
days, 8 cases; from July 9 to July 24, or 
in 16 days, 8 cases; from Oct. 2 to Oct. 
15, or in 14 days, 6 cases; from Dec. 5 to 
Dec. 30, or in 26 days, 6 cases. In 1891, 
from Jan. 6 to Jan. 29, or in 24 days, 6 
cases. 

When one remembers that the average 
number of cases would only be three in 
one month, one can see how that many of 
the cases occurred within a short time of 
each other. This list includes 81 of the 
299 cases. It is remarkable also that the 
most of this "bunching" of cases occurred 
between the months of October and Feb- 
ruary. In the above list, between March 
and August there occur only 16 cases; all 
the rest occur between September and Feb- 
ruary, or 65 cases. 

Nevertheless, this occurrence of cases at 
certain times of the year is in part acci- 
dental, for if 1 included all the other cases 
in this division (193) we would find the 
dilference no longer marked; 88 falling 
between the months of March and August, 
and 105 between September and February. 
Yet this periodical "bunching" of cases 
seems so remarkable that I cannot regard 
it merely as accident or coincidence. No 
explanation can be given for this. The 
changes of temperature or weather cannot 
be responsible. 

'Among the writers on the subject of 
eclampsia, Delore * is the only one, apart 
from myself, who has noticed this pecul- 
iarity. 

Regarding the serological factor of the 
disease, I can only offer additional con- 

* Delore, Lyon Medical 10, XII. , 1884. 



Clinical Lectures. 



Vol. lxvii 



firmation to the well-known facts that 
experience has already taught us. 

Among the 200 parturients affected with 
eclampsia, 145 were primiparae and 51 
multiparas ; the birth number in four cases 
was not known. 

The proportion of primiparae, accord- 
ing to my own observations, was 74 per 
cent; Lohlein gives this proportion as 85.4 
per cent.* and 75 per cent. ;f Schauta 
gives it as 82.6 per cent; J Brummerstadt 
as 80.5 percent, ||and C. Braun as 86.3 per 
cent. § 

Among the primiparas there were no less 
than 37 subjects of 28 years or over. The 
percentage of ''old primijjarae being -25 
per cent. Lohlein gives a percentage as 
29 per cent. 

Of the multiparas 32 had borne two to 
four children, while 1 9 had given birth to 
five or over. These included 5 who had 
borne ten or eleven times. 

Among the 200 cases there were 16 cases 
of twins, making 8 per cent, instead of the 
usual proportion of 1^ per cent, in nor- 
mal births. Lohlein gives the percentage of 
twins in eclampsia as 4.7 per cent.,** 
Winckel as 11 per cent.f f and Schauta as 
7.9 per cent. J J 

Regarding the number of patients taken 
with eclampsia during pregnancy before 
labor, I would not care to give any figures 
as a result of my own experiences. Nearly 
all the patients that came under my care had 
had more or less numerous attacks before 
being brought to the clinic, and the most 
of them were in labor. Lohlein considers 
that 4.7 per cent, develop the disease 
during pregnancy; Schanta places this 
number at 14 per cent. Winckel at 23 per 
cent, and Braun at 24 • per cent. The 
cause of difference in these figures is easily 
understood, when one stops to consider 
that at the time of the physician's ex- 
amination it is often impossible to deter- 
mine with positiveness if the birth was 
already underway or not. With but very 

*Lohlein Zeitschrift f. gebli. und Gyn. Vol iv, 
p88. ■ 

fLohlein Gyncek Tagesfragen, Vol ii p 81. 

JSclianta Archiv. f. Gyn., Vol xviii p 263. 

||Brummerstadt,Bericlit and Rostocker Hebam- 
manlehranstalt, 1865. 

|C. Braun, Braun, Chierian Spath's Obstetrics. 

** Lohlein, Gyn, Tagesfragen. 

ft Winkel, LehrbucJi der Gebutsludfa 1889, page 
580. 

XX Shauta, Arch. Gyn., Vol. xviii, page 263. 



few exceptions the birth and eclampsia 
begin within a short time of each other. 

According to my belief the high per- 
centage of Braun comes nearest the truth, 
but it is also too low. An examination of 
the f oeti born eclamptically will make this 
almost a certainty. When we regard the 
number that are reported as premature 
births, or accept as such all children weigh- 
ing less than 2,250 grammes (less than 2000 
grammes for twins) still the true number 
of premature births will be underrated. 
Nevertheless out of 161 in which I was 
able to make this investigation, 49 were 
found to be premature, or 30 per cent. 

In the majority of these cases both the 
weight and length of the foetus was so 
small that even the eighth month of 
pregnancy could not have been reached. 
Only 5 out of those specified as premature 
births, ever reached the weight of 2000 
grammes. It seems, therefore, that the 
percentage of 30 percent., is far too small, 
and that the actual number of premature 
births would reach to 40 per cent, or over. 
This can be easily explained by the frequent 
occurrence of the disease during pregnancy, 
and the then almost immediate occurrence 
of labor. 

This fact is of great importance in the 
consideration of the various theories that 
have been advanced concerning eclampsia. 
But at present it is not sufficiently well 
known or authenticated. Yet, in Fen- 
stell's * dissertation on the subject we find 
that in 80 cases of eclampsia he regarded 
the percentage of premature births as 
37.75 per cent. 

I will also state that I have observed 
eclampsia in the third and fourth months 
of pregnancy, f 

The percentage of sensu strictori in 
puerperal eclampsias can be accurately de- 
termined. Among these should be in- 
cluded all those cases occurring during 
the after-birth period. So, among my 200 
cases, I found a percentage of 14 per cent. 
Similarly, Winckel found 17 per cent. ; 
Lohlein, 23 per cent.; Schauta, 26.4 per 
cent., and 0. Braun, 24 per cent. 

Among my cases there were five in which 
the eclampsia occurring during pregnancy 
passed without causing the birth of the 
foetus. But all five — partly at home and 



*See Maye, Dissertation, Halle, 1869; Cases I 
and III. 
f Berlin, May 4, 1888. 



July 2, 1892. 



C linical Lectures. 



3 



partly at the clinic — gave birth to mace- 
rated f ceti later on, but without any recur- 
rence of the eclamptic attacks. Our cases 
have shown that if eclampsia occurs during 
pregnancy and passes without causing the 
eruption of the foetus, it will not recur 
again at the birth of the foetus. 

It usually occurs in connection with the 
death of the foetus,* and from this fact 
the theory may be deducted that eclampsia 
may be due to an intoxication produced 
from the living foetus. Against this theory, 
however, is the fact that in many cases 
eclampsia does not occur for a half a day 
or longer after the birth of the child ; and, 
apart from this also, from the fact that it 
not infrequently occurs until long after 
the death of the foetus in the womb. 

Among my cases such an one occurred. 
The patient was a primipara, thirty-two 
years old, who after four eclamptic at- 
tacks, occurring on August 7, gave birth 
to a greatly macerated foetus on August 
10. The woman was in the eighth month 
of pregnancy. After two more attacks, 
one on August 17 and 18, respectively, 
the patient recovered. The urine con- 
tained large quantities of albumin, cylin- 
ders, and renal epithelium. The treatment 
consisted in the exhibition of 0.03 gramme 
of muriate of morphine after the fifth, and 
0.06 gramme after the sixth attack, and 
also 3.0 grammes of chloral by the rectum, 
in injection. 

Braun has also reported two cases of 
eclampsia occurring when the foetus was 
already macerated. That after the death 
of the foetus the eclampsia does not recur 
at its subsequent birth, may be explainable 
by the almost constant and rapid decrease 
of the volume of the uterus after its death. 

Although the return of eclampsia, which 
has ceased for twenty-four hours, is rare it 
occasionally occurs, nevertheless. We had 
experience with such a case. The patient 
was a primipara, twenty- one years . old, 
who on the day of the birth- of a living, 
yet undeveloped child (weighing 1,360 
grammes and measuring 40 centimetres in 
length), on May 24, 1887, had several 
eclamptic attacks. The treatment consist- 
ed in the administration of 0.02 gramme 
of morphine and 3.0 grammes of chloral. 
The eclampsia returned on May 31, the 
seventh day after the birth of the foetus. 



*Wi-nckel, Lehrbuch der Geburtshtilf, 1889, 
page 587. 



At this time she had two attacks. Mor- 
phine in 0.04 gramme doses was -given. 
Eight days later (June 8) she again had a 
single attack. The urine was rich in al- 
bumin (two-thirds of its volume), and 
contained also many hyaline and granu- 
lated cylinders. The patient recovered. 

Another similar case I experienced in 
former years. In the case in question, 
after eleven eclamptic attacks of puerperal 
eclampsia there occurred a cessation of the 
disease for thirty-six hours. Then, after 
a palpation of the uterus, a thirteenth and 
fourteenth attack occurred and, twenty- 
four hours later, again after the palpation 
of the uterus, the fourteenth attack. This 
was followed by additional convulsions, 
occurring the one after the other, until 
after the one hundred and fourth attack 
the patient died. 

Leudet* also reported long ago, a case . 
of eclampsia which passed, and the al- 
buminuria even disappeared. Yet the 
disease returned again after a lapse of two 
months. 

Eeturn of eclampsia at a subsequent, or 
later child-birth is also a great rarity. Out 
of the 200 cases with which this article 
deals, the previous histories of only two 
cases, showed that they had suffered from 
eclampsia before. The one case was a 
secundipara, twenty- six years old, in 
which the first attack occurred thirty 
hours post-partum. The urine was 
highly albuminous. After a few attacks 
the urine was also found to contain 
blood-corpuscles, hyaline and granular 
cylinders. She ultimately recovered, 
after having eight attacks, which slowly 
followed each other during the course of 
twenty-four hours. 

The second case was that of a woman, 
twenty-seven years old, who had given 
birth to five children. During the course 
of twenty-six hours, she had nine eclap- 
tic convulsions. The urine was completely 
saturated with albumin, and hyaline cyl- 
inders. The eclampsia ceased, but the 
patient died twenty-four days later. At her 
first child-birth she had also had eclampsia.. 

I also recall a third case from my own 
practice, of return of eclampsia at a later 
birth. It occurred in a pregnant women, 
who had all the symptoms of an uncompli- 
cated chronic interstitial nephritis. These 
symptoms included, copious diuresis, 

* Gazette Hebdom. 1854, I, 28. 



4 



Clinical Lectures. 



Vol. lxvii 



moderate albuminuria and hemorrhages 
of the mucous membrane. There were no 
evidences of any acute process. The 
patient also recovered from the second at- 
tack of eclampsia, but died six months 
later from atrophy of the kidneys. 

Lumpe* had occasion to observe eclamp- 
sia at the first, second, and fifth child- 
birth of the same woman. 

I have little to add to the symptomatology 
of eclampsia. Regarding the prodroma, 
I would lay stress upon the frequency of 
the so-called "stomach-ache" together 
with the much more frequent, indeed al- 
most constant, headache. The meaning of 
this gastric pain is entirely obscure to us. 
The symptom is, however, one of great 
importance; for in the advanced months of 
pregnancy, when associated with head- 
ache, almost may be regarded as a 
positive prognosis of eclampsia. At least 
such is our experience. This gastric pain 
might be explainable by the theory that 
some patholgical substance is brought into 
contact with the mucous membrane of the 
stomach, where it not only causes pain, 
but more frequently vomiting. This idea 
seems not to be without good foundation, 
especially when the experiments made in 
the Hitzig Clinic in Halle, are taken into 
consideration, and their discoveries applied 
in this case. Here it was found that after 
subcutaneous injections of morphine, 
the drug was partly secreted upon the 
mucous membrane of the stomach. 

As a prodromal symptom, in one case I 
have seen amaurosis occur while conscious- 
ness still remained. Very soon after this 
the first eclamptic attack occurred. 

Regarding the single later attacks, it is 
well known that they occur without any 
warning whatever. Neither can I recall 
any literature on the subject that says dif- 
ferently. It was all the more astonishing, 
therefore, that we observed three cases in 
which there was an undoubted aura. In 
the one case the patient was able to state 
most precisely that before the attack she 
felt a sensation of falling. Indeed, she 
once called out, "I am falling!" and im- 
mediately after a convulsion occurred. 
The same feeling was complained of 
by another patient — a case of puerperal 
eclampsia — only that she felt this sensa- 
tion after the eclampsia had left her. In 
all she had twelve post-partum convul- 



*Braun's Lehrb. d. gebh. 1857, page 486. 



sions. Simultaneously with the sensations 
named she had ocular and aural hallucina- 
tions. Recovery ultimately resulted. 

In the second patient with aura, this 
was still more remarkable. The case was 
that of a primipara, twenty-one years old, 
who had six post-partum eclamptic con- 
vulsions. She had the sensation of clonic 
spasms in the extremities and, indeed, 
simulated the characteristic movements of 
the arms similar to those observed during 
the convulsions prior to the attack. Yet, 
it was only before three of the attacks that 
she was able to give this index as to their 
advent. Before the other three she had 
no warning. In this case it may not have 
been so much a case of aura as that of 
maintenance of consciousness during the 
first part of the attack, and this would ex- 
plain why, after the third attack, deep 
coma and no aura occurred. I need 
scarcely add that both of these cases were 
those of undoubted eclampsia. The first 
patient gave birth to twins and, prior to 
their birth, had seven convulsions in nine 
hours. The attacks were quite typical, 
and the urine contained large 'quantities 
of albumin. The patient recovered. 

The third case was that of a multipara, 
twenty-five years old, who had given birth 
to three children . After an easy and spon- 
taneous birth of twins, perhaps after the 
lapse of half an hour, the patient suddenly 
loudly called the name of her husband, 
and immediately afterwards had the first 
attack of eclampsia. An hour and a half 
later, after she had suddenly called out, 
"It's coming ! " she had the second attack. 
After three subsequent attacks the eclamp- 
sia ceased. Even the next day the urine 
contained a large amount of albumin and 
a few hyaline cylinders. The second day 
after the eclamptic attacks the patient de- 
veloped psychosis with delirium from the 
poisoning. These symptoms lasted two 
or three days, after which she made a good 
recovery. 

Regarding the conditions of the urine, 
as found in the cases observed by me, these 
differed from those observed by some other 
investigators, in so far. that an abnormal 
condition was much more constant ; indeed, 
almost exceptionally present. Out of the 
histories of the 200 cases, in 32 cases 
nothing is said regarding the nature of the 
urine. This is partly explainable by the 
fact that in several ca»es even catheteriza- 
tion would fail to bring any urine from 



July 2, 1892. Clinical Lectures. 5 



the bladder. Out of the remaining 168 
cases, in four cases only a very small 
amount of albumin, or, perhaps, only a 
trace, was found. All four were primi- 
parae; the one had only one attack; the 
second, three convulsions, ante-partum; 
the third, four convulsions, post-partum. 
All three could only be considered light 
cases. The fourth of these patients, how- 
ever, who had hydramnion, had twenty- 
three cases in five and one-half days, 
and an hour and three-quarters after 
the last attack, was delivered by means 
of the forceps of a foetus which had 
recently died. She recovered. 

Entire absence of albumin was only ob- 
served in one case. The patient was a 
multipara (having given birth to seven 
children), forty years old, and had seven 
eclamptic convulsions. 

In the remaining 163 cases the quantity 
of albumin in the urine was always con- 
siderable. In the large majority of these 
cases it was very copious, so much so that 
in a test-tube filled with urine the albu- 
men would occupy half the space, or in 
some cases completely coagulated the en- 
tire bulk of the urine. 

Fenstell* found albumin present in 79 
out of 80 cases of eclampsia. 

Unfortunately, I can say but little re- 
garding the presence of formed elements 
in the urine, since the examination in this 
direction was often neglected, and still 
more frequently not noted. In 59 cases, in 
the histories of which these data are given, 
a negative finding occurred only in seven 
cases. In the remaining cases there were 
more or less greater numbers of sometimes 
hyaline and sometimes granulated cylin- 
ders. Often renal epithelial cells were 
found and, in four or five instances, blood 
corpuscles as well. 

Regarding the presence of oedema, in 
40 cases we have histories of its presence 
before the eclamptic attack. In 26 cases, 
according to the statement of the patients 
themselves, the oedema had appeared a few 
weeks previously ; in 11 other cases it had 
existed for two or three months. In two 
cases the oedema is said to have been pres- 
ent for five months, and in one case even 
six months. 

In the large majority of cases it was un- 
doubtedly not the question of any long 
standing circulatory disturbance. This 



*Loc. cit. 



view of the case agrees with the usually 
tense nature of the (edema, together with 
the slight amount of swelling. 

Icterus occurs but very rarely, and was 
observed in only two cases. The one case 
was a most severe one with fatal issue; 
the second was a lighter case, ten convul- 
sions occurring after the birth of living 
twins, and the result being recovery. C. 
Braun recognizes the recurrence of icterus 
and speaks of a cholaemic eclampsia. Lat- 
terly, Stumpf has again called attention 
to this complication, which most probably 
is connected with a vascular rupture and 
hemorrhage in the substance of the liver. 

Before going on to a consideration of 
the pathological anatomy of the disease, I 
would say a few words on the loss of mem- 
ory which I have noticed among patients 
recovering from eclampsia ; occurring not 
only from the time of the first attack until 
the return of consciousness, but stretching 
into the period of convalescence, and often 
occurring a number of hours before the 
appearance of the disease. 

In my experience, I met the patient 
whom I first saw twelve hours before the 
first attack and who, during a long con- 
sultation, talked most rationally and was 
in the full possession of her faculties. 
Yet, after her recovery from the eclampsia 
she had no recollection of either the con- 
sultation or other important events that 
occurred within twelve hours of the first 
attack. 

This loss of memory might, under cer- 
tain circumstances, be of legal importance. 
(To be continued in the next issue.) 



THE MANUFACTURE OF ARTIFICIAL ICE. 

Ice was artificially produced in India 
long before the invention of machines for 
the purpose, a fact not generally under- 
stood. In the upper provinces, water was 
made to freeze by exposing it during cold 
nights, in porous vessels, or bottles wrapp- 
ed in a moistened cloth. In Bengal, 
shallow pits were dug and filled nearly 
full with dry straw on which were set flat, 
porous pans containing the water tobe con- 
gealed. Exposed over night to a cool 
wind, the water evaporated at the expense 
of its own heat, and the consequent cool- 
ing took place with sufficient rapidity to 
overbalance the influx of heat through the 
cooled air above, or through the badly con- 
ducting straw below. 



6 



Clinical Lectures. 



Vol. lxvii 



OPHTHALMIA NEONATORUM. 
By C. A. VEASEY, M. D. 

OPHTHALMOLOGIST TO THE PHILADELPHIA 
LYING-IN" CHARITY AXD NURSE TRAIN- 
ING school; ASSISTANT DEMONSTRA- 
TOR OE SURGERY IN THE JEFFER- 
SON MEDICAL COLLEGE OF 
PHILADELPHIA, ETC. 



A LECTURE BEFORE THE NURSE CLASS, THE 
MEDICAL STAFF, THE BOARD OF MAN- 
AGERS AND INVITED GUESTS OF THE 
PHILADELPHIA LYING-IN-CHAR- 
ITY AND NURSE TRAINING- 
SCHOOL. 

Ladies and Gentlemen. — When invited 
by the executive committee of your 
institution to deliver a lecture this even- 
ing upon "Ophthalmia, its causes pre- 
vention and treatment," I was in doubt as 
to whether I should attempt to treat of all 
the varieties of ophthalmia, or only of some 
particular variety that you would perhaps 
come in contact with more than any other; 
and after due consideration I arrived at 
the conclusion that it were better to talk 
of that variety which you will see more of 
as obstetrical nurses, so that you will 
recognize it when you see it and under- 
stand its causes, prevention and treatment. 

The socket in which the eyeball is placed 
is lined by a mucous membrane known as 
the conjunctiva. This membrane com- 
mencing at the outer edge of the lids ex- 
tends backward for a considerable distance, 
and is then reflected forward on the eye- 
ball, that portion covering the lids being- 
designated the palpebral conjunctiva, and 
that part covering the eyeball, the ocular 
conjunctiva. Now, ophthalmia is a dis- 
ease of the eye, characterized by pain, 
redness, intolerance of light and excessive 
flowing of the tears, there being either a 
hyper-secretion or a genuine discharge, ac- 
cording to the variety ; the inflammation for 
the most part being seated in the coats of 
the eyeball, or conjunctiva. The affection 
is sometimes known as conjunctivitis. 

Varieties. — The varieties of ophthal- 
mia are many, the chief among them being 
simple, muco-purulent, purulent, diphthe- 
ritic and phlyctenular, the difference 
between them being more the degree of 
inflammation than the character of it. 

Simple, or as it is sometimes called pal- 
pebral conjunctivitis, is an inflammation of 



the palpebral folds of the conjunctiva, 
that portion which covers the eyeball itself 
not being affected. It is characterized by 
redness, intense itching, burning and a 
sensation as if small grains of sand were 
under the lids, causing a desire to rub the 
eye continually. The causes are numerous 
and varied — such as extremes of tempera- 
ture, this being the case when people tell 
you they have taken cold in the eyes; 
foreign bodies, as pieces of coal dust or of 
shell which are blown into the eyes as one 
walks along the street ; cinders from the 
locomotive of a railway train ; exposure to 
a vitiated atmosphere — a room filled with 
tobacco smoke for example; loss of sleep, 
as lam sure many of you have experienced 
after you have been nursing a tedious case 
all night without having had your sleep on 
the previous day. And one of the chief 
causes is working without glasses when the 
eyes need them, or working with improperly 
fitted glasses. Indeed, we frequently have 
patients come to our offices complaining of 
nothing else but the burning sensation in 
the eyes, with agglutination of the lids 
upon waking in the morning, and almost 
always there is found some error of re- 
fraction which when corrected by proper 
glasses, the other symptoms disappear. 

And these glasses should not be pre- 
scribed by an optician but by a skilled 
oculist, who has made a study of the eye 
from a medical and surgical standpoint — 
in other words, a graduated physician who 
has made a speciality of the diseases of the 
eye. It is frequently remarked by elderly 
persons that when they were young, glasses 
were not used nearly so much as now. 
To be sure they were not, but at that time 
there were not the educational advantages 
to be enjoyed as now. The child was not 
sent to school at so tender an age, and 
urged to work day and night in its en- 
deavors to excel and gain a high degree of 
distinction. So many people "did not gain 
a livelihood by the constant use of the eyes 
then as now. There were fewer profes- 
sional men, fewer scholars — in other words, 
there was less eye work, and consequently 
less eye strain and glasses were not re- 
quired. 

The present age is one of push, energy 
and ability, and to obtain a position in, or 
near, the front ranks of the vast army of 
people who are constantly pushing forward 
in their endeavors to reach the highest 
mountain peak of success, requires much 



July 2, 1892. 



Clinical Lectures. 



7 



persevering labor. It is almost impossible 
to attain any degree of distinction, in the 
present age, without at least a moderate 
general education; and an extensive edu- 
cation in one's particular vocation is abso- 
lutely necessary. To possess this requires 
much time and considerable use of the 
eyes, and in our efforts to hasten our suc- 
cess and excel our comrades, to reach the 
summit for which we have been striving, 
as quickly as possible, we use them incon- 
siderately; hence the weak eyes of our- 
selves and our children, to remedy which 
we are compelled to prescribe glasses, 
which correct the defects and relieve the 
ophthalmia and the strain. Unless the 
cause of the ophthalmia be removed, the 
disease in a short time becomes chronic, 
and the treatment is more or less pro- 
longed; but if taken early, the cause 
searched for and removed, the recovery is 
rapid. 

The muco-purulent variety is really an 
exaggerated form of the simple, the din 3 er- 
ence, as stated above, being only in degree. 
In fact the causes are the same, to which 
may be added contagion, the material 
having come from some other eye and 
having been transmitted either through 
carelessness in not cleansing the hands, or 
perhaps by means of a towel or handker- 
chief, this frequently being the method of 
inoculation. 

The purulent is an exaggerated form of 
the muco-purulent, the dose of the poison, 
as it were, having been larger, the soil 
more susceptible and the discharge being 
pus. 

The diphtheretic is a variety, fortu- 
nately for us, rarely seen in this country. 
As "11 diphtheretic inflammations it is char- 
acterized by the formation of a membrane, 
in this instance it being on the conjunc- 
tiva, and very adherent. The affection 
is inclined to be epidemic and is one of 
the utmost gravity. 

The phlyctenular has the same symptoms 
as the muco-purulent, but is especially 
characterized by the appearance of small 
phlyctenule, or vesicles, on the ocular 
conjunctiva, and it is from these that it 
takes its name. 

The muco-purulent and the purulent va- 
rieties, when occuring in the new-born 
child, are grouped together under the 
head of Ophthalmia Neonatorum, the va- 
riety that is of particular interest to you as 
obstetrical nurses, and to all who are con- 



nected with a Lying-in Hospital; and I 
have passed over the other varieties rapidly, 
each one of which would afford material 
for a whole lecture, merely mentioning a 
few of their chief symptoms, so that we 
might discuss this one at greater length. 
To be sure, gonorrhoeal ophthalmia is to 
be classed with the above group, but as 
this is only purulent ophthalmia from a 
specific cause it is hardly necessary to make 
another variety. The fewer the varieties 
the more easily understood is the disease. 

As in all cases of ophthalmia, the real 
cause of ophthalmia neonatorum is a germ, 
just which particular one has not yet been 
fully determined, and the inoculation 
which takes place in one of two ways has 
been divided into the primary and secon- 
dary, the former taking place during, or 
immediately after, birth; the latter occur- 
ring in those cases in which there has been 
a sufficient length of time since the birth 
of the child to enable us to be sure that 
the affection is a result of post-partum in- 
oculation. 

The primary inoculation may be made 
in several ways, It frequently occurs in 
making manual examinations in face pre- 
sentations; the eyelids are sometimes 
opened by instruments, allowing the vag- 
inal discharge to enter; the mucous is 
sometimes retained on the lids after birth, 
sufficient care not having been taken to 
cleanse them thoroughly, and at a later 
period entering the eye causes the dreaded 
inflammation; and again, a very frequent 
cause is the direct introduction of the con- 
tagious material caused by the opening of 
the eyelids by the tense perineum as the 
head is passing through the external ori- 
fice. This may at first seem to you to be 
improbable, but when you consider for a 
moment how very tense the perineum is 
and how the head is elongated, causing the 
eyes of the child to bulge forward, it is 
very easy to understand how, in passing- 
over this taut, elastic structure, stretched 
to its utmost capacity, the palpebral fissure 
may be opened and the contagion intro- 
duced. Clinically it has been determined 
that males are more frequently attacked 
than females, owing to the fact that the 
head is usually larger, and the children of 
primipara? more frequently than those of 
multipara?, on account of the tediousness 
of the labor and the lesser degree of peri- 
natal elasticity and the weak expulsive pains 
toward the end. 



8 



Clinical Lectures. 



Vol. lxvii 



The secondary inoculation is caused by 
failure on the part of the person receiving 
the new-born infant to cleanse immediately 
everything from the eyelids, in the man- 
ner which I will explain to you later; by 
direct contact with unclean materials, 
such as towels, sponges, etc., and in a 
manner that frequently occurs, by bathing 
the face and eyes with the same water with 
which the body has been sponged. Of 
course irritants, like soap, bay rum, bright 
lights, etc., may cause a mild type of con- 
junctivitis, but not the horrible ophthal- 
mia neonatorum of which we are speaking. 

Symptoms. — The symptoms, which may 
be divided into four stages, we are all 
familiar with. First, we have the period 
of inoculation, which usually is only a few 
hours ; then a short period in which lymph, 
the exudative material that always accom- 
panies inflammation in any part of the 
body, is freely secreted, and this is fol- 
lowed by the copious discharge of pus 
which is virulently contagious. There are 
present, of course, the characteristic pain, 
redness, swelling, intolerance of light, 
and a copious discharge. But if every- 
thing goes well the fourth stage is marked 
by the gradual disappearance of the secre- 
tion and a recession of the inflammation. 

The pain caused by this affection is of 
the most excruciating character. To give 
you some idea how severe it is, an incident 
that happened several years ago, and has 
been recorded, is worth relating. At one 
time a slave ship sailing on the high seas 
had an outbreak of purulent ophthalmia on 
board. The ship was some distance from 
land and there were about three hundred 
slaves below the decks affected with the 
disease. No treatment was instituted at 
this time, but a little later some of them 
were allowed to come on deck to get some 
fresh air, and the suffering was so intense 
that most of those who had been allowed 
to come up committed suicide by jumping 
overboard. The great majority of those 
who did not meet this fate became totally 
blind. 

Progress and Termination. — If no 
complication presents itself and the disease 
does not pass into the chronic form, it 
usually lasts from three to four weeks. If 
it terminates directly in a cure, all of the 
symptoms gradually diminish, and the 
conjunctiva returns slowly to a healthy 
condition. If any complication arises, 
however, or if the case passes into the 



chronic form, the affection becomes one of 
the greatest gravity. Small granulations 
begin to grow on the lids and what is 
known as granular conjunctivitis super- 
venes, a disease very difficult to eradicate, 
and the results may be opacities of the 
cornea, that part of the eye through which 
we see. This, of course, causes more or 
less impairment of the vision, and if the 
disease progresses it may result in a per- 
foration of the cornea, or ultimate blind- 
ness. 

Prognosis. — The prognosis of oph- 
thalmia neonatorum is not so bad as one 
would at first suppose it to be. But as 
complications may, and do, arise at any 
stage of the disease, and as it is, as before 
stated, the cause of more blindness than 
any other single factor, it is almost crimi- 
nal to neglect those precautions and that 
practice which experience has shown us 
reduces the percentage of cases almost to 
nil. 

Treatment, Prophylactic. — The treat- 
ment of this disease is divided into two 
parts prophylactic and curative. In the 
former division come all of those means 
which are used to prevent the disease. 
First of all the laity should be instructed 
concerning the great danger of ophthalmia 
and that as soon as any inflammation of the 
eye of the new-born occurs, no matter how 
slight, it should at once be reported to a 
regular practitioner. This idea is put into 
execution in many foreign countries, so 
well understood is the danger of the disease, 
and in Sheffield the eye infirmary distri- 
butes cards which read as follows: "If a 
baby's eye run with matter and look red 
after birth; take it at once to a doctor. 
Delay is dangerous and one or both eyes 
may be destroyed if not treated immediate- 
ly." This advice cannot be too greatly 
emphasized, and it would be an excellent 
step towards the prevention of much 
blindness if all, or indeed some, of our in- 
firmaries followed the same practice. 
Better still if our municipal authorities 
would take the matter in hand and distri- 
bute printed circulars to each family, ex- 
plaining the dangers of the disease and 
stating what should be done in case of an 
attack of it. 

In some countries stringent regulations 
have been adopted as regards midwives and 
nurses, which are not only a protection to 
the infants but also to the nurses, as by 
following stated directions they are freed 



July 2, 1S92. 



Clinical Lectures. 



9 



from all blame. In New York state the 
following has recently been enacted: 
•'Should any midwife or nurse having 
charge of an infant in this state notice 
that one or both eyes of such infant are 
inflamed or reddened at any time within 
two weeks after its birth, it shall be the 
duty of said midwife or nurse so having 
charge of such infant to report the fact in 
writing within six hours to the nearest 
health officer, or some legally qualifiad 
practitioner of the city, town or district 
in which the parents of the infant reside/' 
Some such law enacted in every state 
w T ould cause the number of the most 
hopeless and helpless or all people, the 
blind, to be reduced in our public in- 
stitutions. 

In the beginning of the second stage of 
labor the vagina of the patient should be 
thoroughly irrigated with a solution of 
corrosive sublimate (strength 1-2000), or 
a solution of some other germicide as the 
obstetrician may prefer, but according to 
my belief corrosive sublimate is the best in 
use at present. The hands of the phy- 
sician and the nurse, as well as all the 
instruments employed, should be thor- 
oughly disinfected. The foetal eyes should 
be assisted to pass over the perineum with- 
out resting, for, as I have stated else- 
where, ophthalmia is frequently caused by 
the palpebral fissure being opened during 
the passage of the head over the tense 
perineum and the contagion thus intro- 
duced. The eyes can be made to pass 
over rapidly by hooking the middle finger 
of one hand over the perineum and draw- 
ing it downward. 

As soon as the head is born, if there is 
time, the eyes should be wiped with small 
pieces of absorbent cotton or wool; and if 
there is not time before the birth of the 
body, it should be done before the cord is 
tied. In doing this the cotton should be 
loosely packed into small pledgets and the 
eyes very gently wiped from above down- 
ward, which will facilitate the removal of 
any foreign material that may have accu- 
mulated around the eyeball. As soon as 
this is finished two drops of a five-grain 
solution of nitrate of silver should be 
dropped into each eye, though of course 
this cannot be done without the order of 
the physician in charge of the case, and I 
regret to be compelled to add that many 
do not seem to think it is necessary to take 
any such precaution, notwithstanding the 



fact that statistics show this disease to be 
the greatest known cause of blindness, and 
that when the above prophylactic treat- 
ment is used the percentage is reduced 
from ten per cent, to almost nil. 

The above is known as the Crede method, 
wdrich has been slightly modified, the origi- 
nal being to instill one drop of a ten-grain 
solution of nitrate of silver into each eye. 
Ascertaining that as a rule this solution 
was stronger than required and excited too 
great a degree of inflammation, it is my 
custom to have instilled into each eye two 
drops of a five-grain solution, which, 
though it may contain the same amount 
of silver, does not affect the conjunctiva 
so severely as does the stronger solution. 

There is another method, known as the 
Hegar-Korhn, which consists in wiping 
the face and eyes immediately after birth . 
with a solution of corrosive sublimate 
(strength 1-1000), and though statistics 
show very good results, I prefer the in- 
stillation of the astringent, believing it to 
be the surer and better method of pre- 
vention. In one thousand cases treated 
by the Crede method not a single case of 
ophthalmia developed, w r hile without it 
about 10 per cent, of all infants are af- 
fected with the disease. In the foundling 
hospitals of Paris the percentage of cases 
twenty years ago was from 80 per cent, to 
90 per cent., while to-day it is 0.2 per 
cent., it being compulsory to use the - 
Crede prophylactic treatment. 

The face of the child should never, 
under any circnmstances, be washed with 
the same water with which the body has 
been bathed, and different sponges or 
pieces of flannel should be used for the 
face and body. The reason is understood 
without being given. 

It is very important that you should al- 
ways wash your hands thoroughly after 
adjusting the mother before you touch the 
child, and you should guard against expos- 
ing it to any draughts, bright lights, etc., 
or allowing any soap to get into the eyes. 

Curative. — Should you be so unfortu- 
nate as to have the disease occur the 
child must be isolated at once, and the 
physician notified. 

If one eye only is affected the other 
should be guarded by covering it with 
a light bandage. The physician will 
instruct you to cleanse the eye every hour 
(perhaps more or less frequently than this, 
depending entirely upon the severity of 



10 



Clinical Lectures. 



Vol. lxvii 



the case) washing it first with warm water 
then with a solution of boric acid. 

The best way to do this is to have 
some one sit in front of you and hold 
the child so that its head rests be- 
tween your knees, with its face looking 
upward, your lap being protected with a 
piece of gum cloth or a towel. The per- 
son in front holds the child's legs under 
her left arm and supporting the body on 
her raised knees, has her right hand at 
liberty, with which to assist you. In this 
position the eyes can be irrigated and the 
applications made to the conjunctiva with 
the least possible trouble. 

To reduce the inflammation cold com- 
presses are used. I prefer to have these 
made out of small pieces of lint, about the 
size of the one I show you here, and kept 
on ice which cools them more thoroughly 
than water. They should be placed on 
the eye four in thickness and at first they 
should be changed every minute, the time 
between the applications being gradually 
lengthened. The compresses not only re- 
duce the inflammation by processes which 
I will not describe to you this evening, 
and which are readily understood by every 
practitioner ; but it is also claimed that 
they either destroy or prevent the devel- 
opment of the germ that causes ophthal- 
mia., it having been proved by experiment 
that the said germ cannot develop at, or 
below, a temperature of 32° F. 

The eyelids are everted at stated inter- 
vals by the physician and applications of a 
solution of nitrate of silver made to the 
mucous membrane, great care being taken 
to apply it to all the folds. This stops 
the growth of the germs and substitutes 
a healthy for non-healthy inflammation. 

Other applications rather than nitrate 
of silver are frequently made, among them 
being insufflations of iodoform, calomel 
and solutions of tannin, corrosive subli- 
mate, peroxide of hydrogen and many 
others too numerous to mention. In my. 
own experience I have always found the 
solution of nitrate of silver to be the best, 
though it should not be used indiscrimin- 
ately, nor applied, as many advise, with a 
camel's hair brush; but small pieces of 
cotton should be rolled on the end of a 
stick, as I show you here, dipped into the 
solution and touched to all parts of the 
conjunctiva, one being used for each eye, 
and burned immediately afterward, as 
should bo all the pieces of cotton or lint 



which come in contact with the eye. But 
no method will be of avail unless the phy- 
sician is ably supported by the nurse in 
the thorough and frequent cleansing of the 
eye ; for no matter what the character of 
the applications may be they will not rid 
the eye of the micro-organisms nor pre- 
vent their multiplication unless the nurse, 
with whom the case is entrusted, keeps the 
organ cleansed of all discharge during 
the intervals between the applications. 
And when you have become tired and 
weary and exhausted from nursing such a 
case and feel disposed to neglect it, even if 
only for a few moments, let me beg of you 
to look at the subject from a humane 
point of view, for I know of no act of 
charity or benevolence more praiseworthy 
than that of saving the eyesight of an 'in- 
fant unable to help itself, and thus pre- 
serving its future usefulness for its family, 
for mankind at large and for its Maker ; 
and in after years when that same infant, 
now grown to manhood or womanhood, is 
able to realize the escape it had from blind- 
ness, much of which was due to your care- 
ful nursing and your faithful attention, 
though you may not be aware of it, he 
will heap upon your head heartfelt bless- 
ings and praises, such as we. all desire and 
can only obtain through our own efforts. 

I have added to these remarks some sug- 
gestions collected from various sources 
which I have placed together as so many 
rules. In giving them to you I do so in 
part as a recapitulation, and perhaps am 
guilty of repetition ; but if in so doing I 
am enabled to impress upon your minds 
some important facts relating to the disease 
and its prevention, so that you will in the 
future use them, I feel quite confident 
that you will assist very much to lessen 
the number of cases of ophthalmia neona- 
torum, and thereby in reducing the num- 
ber of blind in our public institutions ; and 
the purpose of my lecture will have been 
accomplished. 

1. Before making a vaginal examination 
always cleanse the hands thoroughly with 
soap and warm water, followed by some 
antiseptic solution, taking care not to for- 
get the finger-nails. 

2. During labor assist the eyes to pass 
rapidly over the perineum. 

3. Always cleanse the eyes of the infant 
in the manner I have explained to you im- 
mediately after birth. 

4. Do not use the same water, for bath- 



July 2, 1892. 



Communications. 



11 



ing the face and eyes, with which the 
body has been bathed, and always use 
different sponges or pieces of flannel. 

5. Never employ one towel for two per- 
sons. Let everybody have his own. " 

6. Be careful not to allow any soap or 
bay rum to enter the eyes. 

7. Keep the light in the lying-in 
chamber very dim, or have it shaded with 
some dark material, green being the least 
trying and the most restful to the eyes. 

8. Always burn immediately everything 
that has come in contact with the ophthal- 
mic discharge. 

9. Instruct the laity, whenever the op- 
portunity presents itself, of the great 
danger of ocular affections of the new- 
born, and the necessity of consulting a 
physician as soon as they are discovered. 

And to the members of the profession 
present I would add: 

10. Always use the Crede, Hegar-Korhn 
or some such method of cleansing and 
stimulating the eyes of a new-born infant. 



EYE AFFECTIONS IN MALARIA. 

Bagot [Ann. d 1 Oculist., January 1892) 
records the following cases which occurred 
at Guadeloupe. The first patient was a 
mulatto boy of 15, who. had a severe bilious 
remittent fever with gastro-intestinal symp- 
toms and coma; this lasted two or three 
days, and immediately afterward his sight 
began to be affected ; three months later it 
was found that he had a soft cataract in 
each eye. The second patient was a mu- 
latto girl of 16, who also had an attack of 
grave malarial fever lasting three days, and 
immediately afterward her sight began to 
fail; nine months later she also was found 
to have a soft cataract in each eye. The 
third case was that of a little white girl, 
who had an attack of malarial fever with 
delirium, convulsions, and loss of con- 
sciousness lasting two days; then, for a 
whole day she complained of red vision, 
and after that her sight rapidly deteriorated 
until the fifth day, when she was absolutely 
blind.. An incomplete opthalmoscopic ex- 
amination at this time revealed a retinal 
haemorrhage in the neighborhood of each 
macula. A year later she had atrophy of 
both discs; with the right eye there was 
perception of light ; the left had improved 
more and she could see to go about, and 
had fairly good color perception. — Brit. 
Med. Jour. 



Communications, 



DIPHTHERIAL 



ByE.FLETCHERINGALS,A.M.,M.D., 
chicago, ill. 



Diphtheria may be defined as a specific 
contagious disease, characterized by pro- 
nounced constitutional symptoms and in- 
flammation of the mucous membrane of 
the fauces and upper air passages, with 
exudation of inflammatory lymph, which 
rapidly becomes formed into false mem- 
brane. 

It has long been recognized as one of 
the zymotic fevers. Many English authors 
consider it a constitutional disease with 
local manifestations, but among conti- 
nental physicians and American writers 
there are many who regard it as a primary 
local affection with secondary constitu- 
tional symptoms. Personally, I am inclined 
to accept the former view, and can see no 
more reason for regarding this as a local 
disease than for regarding vaccina in the 
same light. To me, the peculiar false 
membrane formed in the fauces appears 
analagous to the peculiar vesicle developed 
after inoculation with vaccine virus; and 
the fact that there is a distinct period of 
incubation extending sometimes over many 
days before there is any development in 
the fauces, together with the fact that in 
some instances the disease runs to a fatal 
termination within a few hours and before 
there has been any appreciable local mani- 
festations, seems to prove this position. 

The disease manifests itself in the throat 
by hyperemia, soon followed by the ex- 
udation of inflammatory lymph and deposit 
of false membrane in one or more places 
upon the surface, and this membrane may 
ultimately extend to the air passages or 
may be found upon wounds which may 
exist in other parts of the body. Upon 
post-mortem examination of those dead of 
the disease, blood clots are usually found 
in the heart or large arteries. The lymph- 
atics at the angles of the jaw are enlarged 
and the kidneys are generally deeply con- 
gested. Various bacteria? have been found 
in the mouth of those suffering from diph- 
theria, most of. which, however, may also 

*Read before the Illinois State Medical Soci- 
ety, at Yandalia, May, 1892. 



12 



Communications. 



Vol. lxvii 



be found in the buccal secretions from 
healthy individuals. 

JEtiology. — The disease is undoubtedly 
contagious and may be transmitted from 
man to lower animals and vice versa, but 
the degree of contagiousness varies in 
different epidemics. The affection is 
generally believed to be due to a specific 
micro-organism, "the identity of which is 
not as yet fully established. The researches 
of Pruden in 1869 pointed to a strep- 
tococcus as the probable cause of the 
disease, but most bacteriologists now at- 
tribute it to the Klebs-Loffler bacillus. 
This bacterium is a microscopic rod about 
the length of the tubercular bacillus, but 
twice its thickness It is usually more or 
less bent, with rounded extremities, one 
or both of which may be thickened, giving 
the club or dumb-bell appearance. It is 
immobile and contains no spores. These 
bacilli do not readily absorb the common 
analine stains, but may be colored by the 
solution of Loffier's methylene blue, the 
coloration often. being most intense at the 
extremities. According to Amand Ruff er, 
these bacilli are found most abundantly in 
the superficial portions of the false mem- 
brane, and nearly all experiments go to 
prove that they do not often enter the 
lymphatics or blood vessels. Therefore, 
of itself, the bacillus is apparently innocu- 
ous, but it secretes a virulent toxalbumen 
or ptomaine easily absorbed, which, when 
injected into the circulation, produces 
constitutional symptoms similar to those 
of diphtheria. Numerous clinical obser- 
vations and experiments have, however, 
demonstrated with an equal degree of 
certainty that pseudo-membranous inflam- 
mation is often produced independently of 
this bacillus, as for example, that result- 
ing from surgical injuries to the throat, 
or various chemical caustics; and they 
have also shown that certain exudative in- 
flammations supposed to be of microbic 
origin, as for example, those frequently 
observed in scarlet fever and measles, are 
not attended by the development of 
the Klebs-Loffler bacillus. These latter 
inflammations have been termed psueclo- 
diphtheria, and it is stated that they can 
only be distinguished from true diphtheria 
by the absence of the Klebs-Loffler bacillus, 
by their being followed by paralysis, and 
by not being attended by a peculiar form 
of albuminuria which occurs in true diph- 
theria independently of dropsy or uremic 



poisoning. The necessity for assuming 
that there are two varieties of diphtheria, 
seems to me to justify the statement made 
in the beginning, that the identity of the 
micro-organism, which is supposed to 
cause the disease is as yet uncertain. 

Primary inflammation of the fauces ap- 
parently greatly favors the development 
of diphtheria, and its development and 
progress seem to be largely influenced by 
bad hygienic surrounding, such as impure 
drinking water, sewer gas, and the eman- 
ations from decaying vegetables and un- 
clean cellars; but it is doubtful whether 
any of these conditions can of themselves 
produce the disease. 

The most frequently predisposing cause- 
of diphtheria is exposure to cold, more par- 
ticularly in the spring and fall months, 
when the temperature of houses is liable 
to be kept at from 65° to 68° F. At this 
time adults moving about the house do not 
realize the necessity for fire, but the little 
children upon the floor are exposed to a 
temperature two or three degrees lower ; 
or during the morning or evening, they 
are allowed to run about for sometime in 
their night clothing and thus contract 
colds, which are peculiarly prevalent at 
these times and which favor the develop- 
ment of diphtheria. - 

Symptomatology. — After a period of 
incubation varying from one to eight days, 
this disease is usually developed in young 
children with pronounced constitutional 
symptoms, such as headache, drowsiness, 
fever, thirst, and sometimes vomiting and 
diarrhoea. The little one usually complains 
of stiffness of the neck, and within a few 
hours of sore throat. In older children or 
adults, the symptoms are commonly much 
less pronounced, and the disease develops 
more gradually ;the sore throat is attended 
by sensations of dryness and slight pain, 
with an inclination to frequently hawk and 
clear the throat. Usually within twelve 
to thirty- six hours a false membrane 
begins to form upon the tonsils and in 
rare instances an erythematous eruption 
appears upon the skin. The pulse is .rapid 
and as the disease progresses, becomes 
small, feeble and intermittent. The tem- 
perature at first seldom rises above 101°' 
or 102° F., but on the appearance of false 
membrane it usually falls and may even 
become subnormal. During the third or 
fourth day of the attack it is likely to rise 
again, indicating in favorable cases sup- 



July 2, 1892. 



Com mimications. 



13 



puration and oxfoliation of the false 
membrane ; or in those which are progress- 
ing unfavorably, extension of the disease 
to the larynx, the lower air passages, or to 
the intestinal canal. A sudden fall of 
temperature after four or five days is a 
symptom of grave import. When the disease 
extends to the larynx the voice soon be- 
comes affected and may be weak and hoarse 
even before the false membrane is deposit- 
ed, but with the deposit of pseudo-mem- 
brane upon the vocal cords the voice 
becomes aphonic, the cough less intense, 
and dyspnoea develops proportionate to 
the amount of obstruction. In this condi- 
tion the respiration becomes noisy and 
stertorous and the dyspnoea is constant, 
aggravated from time to time by spasms of 
the laryngeal muscles. With these 
paroxysms all the distressing symptoms of 
suffocation appear. 

The deposit of false membrane fre- 
quently extends to the naso-pharynx or 
nares, causing obstruction and a sanious 
discharge, and later epistaxis. The tongue 
is commonly heavily coated and there is a 
peculiar odor of the breath, which is al- 
most pathognomic. Anorexia, nausea, 
and vomiting are common, especially when 
the kidneys are much involved, and al- 
buminuria is present in nearly all cases 
from early in the disease. The glands of 
the angles of the jaw are enlarged, and as 
as a rule, the greater the swelling, the 
more severe will be the attack. Inspection 
of the throat reveals: first, congestion; 
and shortly after, thin strips of yellowish- 
white false membrane, which rapidly 
extend over one or both tonsils, and in 
more severe cases, to the surrounding 
mucous membrane. With the progress of 
the disease, the membrane becomes grayish, 
brownish, or even almost black in color, 
it has the appearance of involving the 
mucous membrane and being slightly 
elevated above its free surface. When ex- 
foliated, or forcibly removed, an ulcerated 
granular or bleeding surface will be found 
beneath it, though not usually co-extensive 
with the false membrane. When the glot- 
tis becomes obstructed, the respiratory 
movements become slow and labored and 
recession of the soft parts of the chest 
above the clavicles, at the ensiform appen- 
dix, and over the false ribs is noticed with 
each inspiratory movement. The skin is 
cold and pallid, and may be bathed in cold 
perspiration. The lips, ringer nails and ears 



appear livid, and as the carbonic acid poison- 
ing progresses, the patient may become 
extremely restless, or fall into a semi- 
comatose condition. With the paroxy- 
smal spasms of the glottis, the well known 
symtoms of imminent suffocation are de- 
veloped and death may speedily ensue. 

Diagnosis. — Diphtheria is not likely to 
be mistaken by the experienced physician 
for any disease except follicular tonsillitis 
and simple membranous sore throat; 
though in some cases, it may be a difficult 
matter to distinguish between diphtheria 
and the pseudo-membranous forms of scar- 
latina or measles. The essential points of 
difference between diphtheria and follicu- 
lar tonsillitis are; in follicular tonsillitis 
there is higher temperature, commonly two 
or three degrees more than that of diph- 
theria; there is much more pain in the 
throat, and difficulty of opening the mouth 
which is not usually present in diphtheria, 
the swelling of the tonsils is greater, and 
there appear a number of small yellow 
spots where secretions have collected in the 
follicles, instead of one or two uniform 
patches of false membrance spreading over 
a considerable part of the throat. 

In simple membranous sore throat, at 
first there are numerous herpetic vesicles, 
but after two or three days these are 
covered with a membrane similar to that 
of diphtheria, though it is not so thick . 
and more easily removed. Commonly - 
also, there are several patches of this false 
membrane, and herpes labialis is apt to oc- 
cur at the same time. The pain is simple 
membranous or as it is sometimes known, 
herpetic sore-throat, is usually very much 
more intense than in diphtheria. 

There is usually no difficulty in distin- 
guishing between diphtheria and scarlatina 
or measles, but sometimes in either of these 
affections the deposit of false membrane in 
the fauces may cause an appearance very 
like that of diphtheria, There is a ques- 
tion whether in such cases there are the 
two diseases combined, or whether the 
pseudo-membrane, as claimed by bacteriol- 
ogists, is entirely different in its origin 
from true diphtheretic membrane. 

Prognosis. — The prognosis of diphthe- 
ria is always grave and we can never as- 
sure the friends that the patient is out of 
danger until he has been well for three or 
four weeks, because of the serious sequelae 
which sometimes follow. I have kuown 
cases to terminate fatally within twelve 



Communications. 



Vol. Ixvii 



hours after the beginning of the attack, 
but in the majority of serious cases a fatal 
termination does not occur before the 
fourth or fifth day, and in a considerable 
number the struggle for life may continue 
five or six weeks. In some epidemics of 
the disease a large percentage of patients 
recover ; but in others twenty-five or thirty, 
or even a large per cent, prove fatal. The 
deposit of false membrane in the nose, or 
naso-pharynx, or intestines; the occur- 
ence of extreme pain in the ears and 
throat, of purpuric spots upon the skin, 
or of epistaxis or other haemorrhages, and 
the presence of persistent anorexia, vomit- 
ing, diarrhoea or suppression of urine, are 
all indications of grave import. Patients 
may die slowly from asthenia or more 
quickly by suffocation, or they may be 
carried oif by heart failure or convulsions. 
Not infrequently paralytic symptoms 
follow the attack about the third week, 
but except in cases where the respiration 
or circulatory centers are involved, recov- 
ery usually occurs, though it may be de- 
layed for weeks or even months, and some- 
times the paralysis is only partially re- 
covered from, more or less loss of muscular 
mobility remaining permanent. 

Treatment. — There are few diseases in 
which the methods of treatment are more 
numerous; a fact which may be explained 
# by the great inutility of the majority of 
means adopted. So much depends upon 
the condition of the patient when attacked, 
upon his hj^gienic surroundings and the 
variety and nature of the particular epi- 
demic, that physicians are necessarily led 
astray in estimating the effect of remedies 
employed. During the early portion of a 
severe epidemic a very large percentage of 
patients may die whatever methods are 
used in the treatment; but later on the 
cases become less and less severe and the 
fatality greatly diminishes, regardless of 
the treatment employed. However, the 
remedies which are in use during the 
latter part of the epidemic are liable to 
receive all the credit. 

Whenever diphtheria appears in a house- 
hold, the greatest care should be exercised 
to isolate the patient, and all other chil- 
dren should be removed if practicable. 
The rooms occupied by the patient should 
be kept carefully closed, the doors covered 
with sheets constantly moistened by anti- 
septics, and the patient and nurse should 
have no intercourse whatever with other 



members of the household. The sick 
rooms should be kept warm and thor- 
oughly ventilated, and finally when the 
attack subsides, the utensils and clothing 
used in the sick room should be disinfected 
or destroyed, and the room thoroughly 
fumigated and aired before it is again used; 
even then it is well to prevent children 
from occupying the room for several weeks 
afterwards. 

In the beginning of the attack, ice taken 
freely into the mouth tends to relieve 
thirst and reduce congestion and appar- 
ently markedly to limit the progress of 
the disease. Of even more importance has 
seemed to me the application externally of 
ice bags or the ice water coil of metallic or 
rubber pipe applied to the throat. When 
ice bags are used, they should be narrow 
and long and should be about half filled 
with pieces of ice about the size of filberts ; 
the bag may then be folded in a handker- 
chief and tied so that it will extend up to 
the ears on both sides. The ice will need 
to be changed about every hour. Occa- 
sionally patients complain of pain when 
cold is employed and in these, very hot ap- 
plications will be found to answer a better 
purpose, but whether hot or cold be used, 
it must be continuous; otherwise more 
harm than good will result. 

As soon as the membrane begins to sep- 
arate, hot applications appear to be more 
useful than cold. The disease usually 
causes dangerous prostration. Therefore 
the patient should be well nourished from 
the beginning. Liquid diet in the form 
of beef tea, broth, or better yet, milk, 
should be given at regular intervals and in 
large quantities ; about half a pint or its 
equivalent being used as often as every 
third hour. Alcoholic stimulants are rec- 
ommended early by many practitioners, 
but to me they seem unnecessary and un- 
desirable until the stage of depression 
supervenes. Acting on the principle that 
bacteria cannot live in acid solutions, some 
physicians recommend the free use of acid- 
ulated drinks or gargles, and this possibly 
explains the reputation recently attained 
among the laity, by pineapple juice, as a 
cure for diphtheria. Many substances 
have been used with the hope of removing 
false membrane; the simplest of these is 
steam, which may be impregnated with the 
time-honored lime water and applied by 
the croup tent or any suitable atomizer, 
but it is extremely doubtful whether lime 



July 2, 1892. 



Communications. 



15 



in any form is ever applied in sufficient 
quantity to appreciably affect the pseudo- 
membrane. 

Lactic acid is one of the most powerful 
solvents for pseudo-membrane. It has 
been highly recommended in about 15 per 
cent, solution to be frequently employed 
as a gargle or spray ; and in full strength 
to be carefully applied by the physician 
twice daily to the false membrane. Trip- 
sin, resorcin and papain have all been used 
for their solvent effects upon the mem- 
brane, but they seem to have little if any 
influence upon the progress of the disease. 
Tannic acid and alum are used to astringe 
the false membrane, and insufflations of 
sulphur have become extremely popular 
with the laity, but none of these seem to 
have much effect upon the disease. So- 
lutions of mercury-bichloride one to one 
thousand or weaker; of carbolic acid, one 
to three per cent. ; of potassium perman- 
ganate, one per cent.; liquor, sodas chlori- 
nates, five per cent. ; of chloral, about 
thirty per cent. ; or of sulphurous acid, 
from five to ten per cent., have all been 
highly recommended, from time to time, 
as gargles or sprays to destroy the poison- 
ous germs in the throat. Peroxide of 
hydrogen is also used for the same pur- 
pose, either diluted with an equal part of 
water, or in full strength as obtained from 
the pharmacist. Tincture of myrrh, strong 
alcohol, and tincture of the chloride of 
iron have also been recommended, and oc- 
casionally tincture of iodine or a strong 
solution of nitrate of silver are used. I 
believe that strong applications often do 
more harm than good, and any remedy 
which causes the patient pain for more 
than five minutes is likely to be injurious. 
Tincture of iron has seemed to me one of 
the best remedies for local use, as it has 
also appeared for internal administration. 
Kecently I have adopted as a local appli- 
cation, either by means of spray or gargle, 
a saturated solution of boric acid in cinna- 
mon water. The researches of Eoux and 
Yersin in 1889 demonstrated that the 
toxicity of cultures of the diphtheritic 
bacillus are greatly diminished by the ad- 
dition of carbolic acid, borax or boric acid, 
and the experiments of Dr. G. V. Black, 
reported in the Dental Review for Febru- 
ary and March, 1889, have shown that 
the oil of cinnamon, 1 to 2000, is a most 
efficient germicide; therefore, a combina- 
tion of these two appears especially suited 



to the destruction of the diphtheritic bac- 
illus. This application is neither unpleas- 
ant, painful nor dangerous, and from my 
clinical observation, it appears* very ef- 
fective. My common practice in diph- 
theria is to give tincture of iron in large 
doses, about one minim for each year of 
the child's age, combined with an equal 
quantity of glycerine and enough syrup of 
tolu to make one drachm. This dose is 
administered every hour in serious cases, 
or once in two hours where the symptoms 
are less severe. The patient is first given 
three or four swallows of water, so that 
the medicine will not prove irritating to 
the stomach, then the medicine is admin- 
istered in as concentrated a form as can 
be taken without causing pain ; the patient 
is directed to hold it in the throat as long 
as possible, thus- obtaining the effect of a 
gargle, and then it is swallowed. Usually 
as much as ten minims to the drachm will 
not cause pain in the early stages of the 
disease, but later on it may be necessary 
to dilute the dose with water. The gar- 
gle or spray should also be used every hour. 
Thus, one or the other would be adminis- 
tered every half hour except during the 
night, when it is often necessary to allow 
the patient to sleep. However, when the 
disease is progressing it is sometimes 
unsafe to allow the patient to go more 
than half an hour without receiving 
either the gargle or the solution of 
iron. But I would strongly deprecate 
awakening the patient more often than is 
necessary for this purpose, and as soon as 
the membrane ceases to spread, I would 
allow the child to sleep one or two hours 
rather than disturb it to give the medicine. 
Quinine in moderately large doses may 
also be given judiciously, and as the stage 
of depression comes on, alcoholics should 
be used freely, it making little diff erence 
in the progress of the disease whether they 
be in the form of wine, whiskey or brandy. 
Children will often take much more readily 
than any of these a mixture of equal parts 
of alcohol and syrup of tolu which is prac- 
tically of the same strength as good 
whiskey. When the heart fails, no remedy 
is of so much value as some of the pre- 
parations of nux vomica. The tincture of 
mix vomica although liable to variation in 
strength has seemed to me to act more 
favorably than strychnine. Which ever 
preparation is adopted it must usually be 
given in large and frequently repeated 



16 



Communications. 



Vol. lxvii 



doses; to a child of five years of age I have 
given one or two minims of tincture of 
mix vomica, which equal two to four drops, 
every hour for many days, with the great- 
est benefit. I should not hesitate as long 
as the heart continued weak to give half a 
minim (that is one drop) every hour until 
the constitutional effects as indicated by 
twitching of the tendons, were developed; 
the doses should then be slightly diminish- 
ed, or the intervals between them prolong- 
ed. Within the past few years the bichlo- 
ride, and other preparations of mercury 
have been largely used in the treatment of 
diphtheria in doses often much larger than 
could safely be administered to adults. I 
have myself used freely the mild chloride 
of mercury (calomel), with most happy 
results in diphtheritic laryngitis, but I 
have not favored large doses of the other 
preparation believing that a system alreadv 
struggling against the virulent action of 
the toxalbumins is poorly fitted to with- 
stand poisonous doses of bichloride of 
mercury and its congeners. The mild 
chloride of mercury has been highly recom- 
mended for diphtheria and I have no doubt 
that it is beneficial, especially as a cathar- 
tic. I have found it most efficacious in 
instances of diphtheritic laryngitis, and 
have never known it to do harm even when 
given in very large doses. 

Among other remedies which have re- 
ceived the sanction of good authority for 
the curing of this disease, are cubebs, co- 
paiba, potassium chlorate, the sulpho-car- 
bolates and sulphites of sodium and po- 
tassium, and the salicylates and the 
benzoates of potassium, sodium and am- 
monium. Indeed, there are few remedies 
of any potency in any disease which have 
not been tried for this affection and which 
have not, for a time at least, received more 
than merited praise. 

When the disease extends to the larynx, 
non-depressing emetics are sometimes use- 
ful to dislodge the false membrane and 
the mild chloride of mercury in large and 
frequently repeated doses has seemed to 
me most beneficial in preventing its de- 
posit. I have given calomel in such cases 
in doses equivalent to half a grain for 
each year of the child's age, and repeated 
every one or two hours according to the 
severity of the case, until its effects upon 
the bowels were noticeable. It is surpris- 
ing how much of the remedy maybe taken 
in such eases before its characteristic effect 



upon the stools occur. I have seen a child 
two or three years of age take 30 or 40 
grains before the bowels moved. As soon 
as the effects of the remedy are noticed 
upon the stools, the dose should be dimin- 
ished in size and frequency and as soon as 
the dyspnoea is relieved, the remedy should 
be withdrawn. Unfortunately, whatever 
remedies are employed, the false membrane 
will frequently extend to the glottis, as in- 
dicated by difficulty of breathing, blueness 
of lips and finger nails, and recession of 
the soft portions of the chest walls during 
inspiration, when these symptoms occur, 
no time should be lost in adopting opera- 
tive measures, although a certain number 
of cases may be cured by mercurials or a 
small precentage might recover from the 
unaided efforts of nature. 

It is not safe to wait for nature or the 
slow effect of medicine in these cases, for 
statistics have shown that about 95 per 
cent, will prove fatal when the larynx has 
become involved, unless operative measures 
are adopted and even with these only 25 
or 30 per cent, are saved. One of two 
operations may be adopted, the one to be 
preferred depending somewhat upon the 
age of the child and its surroundings. 
Other things being equal, in a child under 
five years of age, I decidedly prefer intuba- 
tion by O'Dwyer's method, though in 
older children it is not quite as satisfactory 
as tracheotomy. Even in quite large 
children intubation has been found useful, 
particularly when the graver operation 
will not be permitted. I would recom- 
mend that it be tried first in all cases, be- 
cause of the ease and rapidity with which 
it can be performed, the avoidance of a 
wound liable to a secondary infection and 
the ready consent of parents, and finally, 
because it is no bar to the subsequent per- 
formance of tracheotomy, should this 
severe operation appear necessary. 

I hope, gentlemen, that you will try in- 
tubation in these cases, and I believe that 
none of you will fail in successfully intro- 
ducing the tubes. The confidence gained 
by two or three intubations will cause the 
physician to recommend the operation 
earlier, and thus protracted dyspnoea and 
the consequent pulmonary congestion and 
oedema will be prevented and many lives 
will be saved that would be lost if the 
operation were delayed until suffocation 
became imminent. There is only one ac- 
cident which is likely to occur in the 



July 2, 1892. 



Communications. 



performance of intubation, namely, the 
crowding downward of loose membrane 
before the tube; this in a few instances 
has caused speedy death. To relieve the 
difficulty all that is necessary is to at once 
withdraw the tube, when the loosened mem- 
brane will be drawn out with it or will be 
coughed out immediately afterwards; but 
in some instances this happy result is not 
obtained, and, therefore, it is well for a 
physician always to have a tracheotomy 
set at hand when about to perform intuba- 
tion, so that the trachea may be opened at 
once if necessary. I have never found it 
necessary to resort to tracheotomy at such 
times, but have long felt it best to be pre- 
pared for any emergency that might arise. 
It is best before doing intubation to ex- 
plain to the friends that there is a bare 
possibility that the child may die before it 
is completed, because of this accident. 
When tracheotomy for any reason becomes 
desirable, it should be done as soon as 
practicable after marked inspiratory reces- 
sion of the chest wails indicates serious 
obstruction of the glottis. 
36 Washington street. 



PATHOLOGICAL ANATOMY OF EXOPH- 
THALMIC GOITRE. 

Mendel {Deutsche medicinische Wochen- 
schrift, February 4, 1892) after calling- 
attention to the poverty of medical litera- 
ture in cases of exophthalmic goitre with 
definite lesions, reports a case observed by 
himself, over a term of two years, which 
was a typical case of this disease. The 
patient died of cardiac paralysis. At the 
post-mortem there were no gross lesions 
observed, either in the brain, spinal cord, 
sympathetic or vagus. Careful micro- 
scopic examinations were made, however, 
of all these parts. The cortical substance 
of the brain, the different ganglia, the 
cerebellum and the vagus were entirely 
normal. Two changes were, however, 
noticed ; first, a difference between the two 
restiform bodies; in a series of 1,210 sec- 
tions of the medulla the left lestiform 
body was seen to be atrophic; second, 
there was evident atrophy of some of the 
solitary bundles in the' right restiform 
bod}. The. author calls attention to 
numerous experiments upon lower ani- 
mals, where symptoms of exophthalmic 
goitre have been caused by a destruction 
of restiform bodies. — Univ. Med. Mag. 



FRACTURE OF THE LOWER JAW. 



By A. 0. STIMPSON, M. D., 

THOMPSON, PA. 



On 1st March, 1888, I was called to go 
and see Henry J. Cleveland of our town 
who was reported as seriously injured about 
the face. On examining the case I found 
a contused bruise of the left side of the 
lower jaw, with a double fracture of 
lower jaw, so that the incisor and canine 
teeth were turned out upon the chin. The 
accident was caused by the man's face 
being compressed and bruised from the 
sliding of a load of hay in a rack from the 
wagon toward the hay mow in the barn 
while attempting to unload it. 

The lines of fracture are indicated by the 




Fig. 1. 



dotted lines (Fig. 1). After washing and 
bathing the face and jaw with an infusion 
of arnica-blows and cider vinegar (used 
warm), I applied a splint as follows: I 
took a piece of sole leather of the 
right length to extend around the 
lower jaw and split the splint like this 
(Fig. 2). I then sewed a bandage of the 




Fig. 2. 



appropriate length to each tail of my im- 
provised splint, and after soaking the 
leather in warm water so as to mould it to 
the shape of the jaw, after padding it with 



18 



Communications. 



Vol. lxvii 



absorbent cotton, I fastened the lower seg- 
ment of the splint over the vertex of the head 
and the upper one on the back of the neck in 
this way (Fig. 3). I extracted one of the in- 




Fig. 3. 



cisor teeth on left side to allow of nourish- 
ment being introduced by means of a rub- 
ber tube, and in twelve days' time the man 
was able to take nourishment in the ordi- 
nary way, but was not allowed to masticate 
any food until the expiration of thirty-two 
days. The patient made a good recovery, 
and to-day you can scarcely trace out the 
line of fracture, either in front or at the 
side of the jaw. 

The point of interest in this case is that 
no sutures of wire or silk were used and 
still the bones were kept in close apposi- 
tion by the simple confinement by the sole- 
leather splint. 



HYDR AMNIOS AND PRESENTATION OF 
HEAD OF ANENCEPHALOUS MONSTER 
DIAGNOSED BEFORE BIRTH. 

Pinzani (Eiv. di Obstet. e Gin., 1891, 
No. 24) attended a patient in whom, four 
days before her confinement, he diagnosed 
the presence of an anencephalous foetus in 
an instructive manner. It was evident 
that the long axis of the foetal body was 
vertical, and careful external examination 
indicated head presentation. On vaginal 
exploration, an irregular surface with nu- 
merous bony prominences was found pres- 
enting. Pressure on this surface set up 
convulsions in the foetus ; this phenomenon 
was observed on several occasions. Hence, 
face presentation was out of the question, 
and an anencephalous monster evidently 
present. The patient was delivered of a 
female anencephalous foetus, which showed 
signs of life for a short time. Childbed 
was perfectly normal. — Brit. Med. Jour. 



CLINICAL NOTES ON A CASE OF 
HYSTERIA IN A BOY EIGHT 
YEARS OF AGE.* 



By SAMUEL AYRES, M. D. 

PITTSBURG, PA. 



The rather infrequent occurence, or per- 
haps recognition, of hysteria in young 
children, induces me to report the follow- 
ing interesting case : 

William T., cet eight years, had good 
family history and previously good health. 
In the early part of December, 1891, while 
attending school, he became involved in a 
quarrel with four boys, who pitched upon 
and struck him about the face and head, 
there being left, however, no visible bruises 
or marks of injury. Immediately after re- 
turning home that evening he complained 
of severe headache, not specially localized. 
This continued without abatement for 
about two weeks, when the family physi- 
cian, Dr. Wallace, of Ingram, was con- 
sulted. After treating the patient a few 
weeks there was still no improvement in 
the headaches, but otherwise the boy's 
general condition was not much impaired. 
He had not been allowed to attend school 
since the accident, but played about the 
house, had a fair appetite, bowels were 
regular, and there was no abnormal varia- 
tion in temperature or pulse. But he was 
pale, and complained of almost constant 
headache. On the advice of Dr. Wallace, 
his eyes were during this time examined 
by Dr. Geo. W. Allyn, who found a low 
degree of astigmatism and prescribed 
glasses. 

On -the morning of January 17th, last, 
the boy had a fainting spell before break- 
fast and became very pale, weak and lan- 
guid, complaining severely of the usual 
headache. At that date Dr. Wallace re- 
ferred the patient to me, and the boy was 
brought to my office on the 18th of last 
January. A careful examination was 
made. Mentally the boy seemed clear, 
and gave prompt answers to all questions. 
His face was rather pale, the pupils widely 
dilated, contracting slightly to bright 
light. The tongue was extruded straight, 
and not much coated. The pulse about 
80°, temperature normal. No abnormal 

*Read before the Allegheny Countv Medical 
Society, May 10, 1892. 



July 2, 1892. 



Communications. 



19 



motor or sensory phenomena were noted. 
The optic discs were normal. The urine 
contained neither albumin nor sugar. 

The headache, of which he only com- 
plained, was referred to the vertex and 
forehead. The nature of the case was not 
entirely clear to me. The cause was ob- 
viously connected with the injury to the 
head, as he had been perfectly well up to 
that time. I therefore inclined to the 
opinion that the case was one of simple 
neuralgia, or else a slight injury to the 
cerebral membrane, perhaps a localized 
patch of congestion in the frontal re- 
gion. 

On this theory I prescribed small doses 
of sodium iodide and sodium bromide; 
also one grain of ergotin three times daily, 
and blistered each mastoid process, In 
three or four days the -boy was brought 
back to my office without any improve- 
ment in the headache. The same treat- 
ment was continued excepting that yi 
grain of protiodide of mercury was sub- 
stituted for the ergotin. A mild galvanic 
current was passed for a few minutes 
from forehead to occiput. The parents 
were directed to discontinue this treat- 
ment in two days if he were not 
better, and to give tablets containing 
three grains of antipyrin every three 
hours. The day following this I was sum- 
moned in great haste by the father to meet 
Dr. Wallace, the former stating that he 
thought his son was dying. It seems that 
the lad complained of being sleepy and 
tired, and sitting on a rocking chair ap- 
parently went to sleep, but at once exhibit- 
ed some general convulsive movements, 
and became wildly incoherent. When Dr. 
Wallace and I arrived, the boy was in bed 
and appeared rather bright and talked ra- 
tionally. His pulse was about 90°, tem- 
perature normal. He complained, as usual, 
of the headache. When questioned as to 
the spell he had just had, he seemed to 
remember nothing about it. Very soon he 
was seized with one of these paroxysms, 
consisting of symmetrical clonic spasms of 
the forearms and hands, the same spasm- 
odic movements passing to the lower ex- 
tremities, the whole attack lasting scarce- 
ly a minute. There was apparently no loss 
of consciousness; no frothing of mouth; 
no change in the color or expression of 
face. At another time there would be a 
rapid turning of the head from side to 
side, or contortions of the entire body, or 



opisthotonus, accompanied by profane 
utterances, or other incoherent outbursts, 
terrifying and shocking his parents. We 
withdrew the iodide, increased the bromide 
to 10 grains every three hours, and gave a 
little tr. of opium and aconite. Broths 
and other concentrated nourishment were 
given and accepted at frequent intervals. 
At our consultation the following day the 
boy was rather worse. The paroxysms, 
above described, had been more severe and 
frequent. The breathing at times had 
been irregular and jerky, diplopia had been 
observed. The head was occasionally re- 
tracted and bored into the pillow. The 
parents stated that he had been very 
"flighty"; that at times his eyes were 
glassy and upturned and that they thought 
in one of these spells he would die. He 
had taken nourishment and slept fairly 
well ? though during sleep there was much 
muscular twitching and catching respira- 
tion. When we entered the room the boy 
greeted us, and smiled and talked intelli- 
gently. We soon got him out of bed and 
tried to have him walk. His gait was very 
unsteady and he settled well back on his 
heels, inclining to fall backwards. But 
with assistance he walked some. 

Replacing him in bed and retiring from 
the room we slightly opened the door. In a 
few moments he had one of the paroxysms 
above described. Gliding in swiftly I press- 
ed firmly on the supraorbital nerve. The ' 
boy immediately ceased his contortions, 
cried with pain, and said I had hurt him. 
We desired no further proof of the nature of 
the case, and the subsequent history con- 
firmed the diagnosis. On appropriate 
treatment, of tonics, outdoor exercise, 
and the ignoring of his headache by 
the family, the boy gradually recovered, 
only once after having hysterical attack, 
which was promptly arrested by the same 
means. 

The fact that the patient was a boy, that 
he was so young, and that the headaches 
seemed to be of traumatic origin, quite 
misled us for a short time, as to the real 
nature of the trouble. 

I will not detain the society with any re- 
marks on hysterical affections in young- 
children. They do, of course, occur in 
children of either sex, much younger 
than this one, but are, I believe, com- 
paratively rare in our country. In France, 
nursery hysteria is by no means uncom- 
mon. 



20 



Communications. 



Vol. ixvti 



THE TREATMENT OF CYSTS AND 
ABSCESSES BY PAPOID AND 
PEROXIDE OF HYDRO- 
GEN. 



By 0. A. HYDE, M. D., 

NEW YORK CITY. 



The first case was one of sebaceous cyst 
at the calf of the leg, the cyst having ex- 
isted for at least ten years, and until recent- 
ly, given but little trouble. When I open- 
ed the sac, it was inflamed, partly broken 
down and about to open at the site of my 
incision. Its cavity contained about 16 to 
20 grams of decomposed sebum and pus. 
I made but a small incision that the fluids 
might be better retained. The solution 
employed was as follows, viz : 

T> Papoid 15 to 20 grams. 

X¥ Sodii Bicarb 5 to 10 grams. 

Aquae 100 c. c. 

This injection was allowed to remain 
from one to eight hours, then pressed out 
of sac, and a strong solution of peroxide 
of hydrogen introduced to thoroughly clean 
the cavity. This was repeated once or 
twice daily. The patient was irregular in 
treatment of cyst, otherwise the result 
would have been obtained earlier. A few 
weeks of this treatment entirely removed 
the cyst wall, and satisfactorily cured the 
case. 

The second case was one of perineal ab- 
scess, that owing to the carelessness of the 
patient had existed for several months, 
during which period it had been thoroughly 
injected daily with peroxide of hydrogen 
solution. The patient was unwilling to 
remain away from his business, and thus 
have the necessary rest for cure, and also 
was troubled with uric acid deposits and 
calculi in bladder. The abscess improved 
under above treatment, but would break 
down occasionally and discharge pus. Sev- 
eral times the urethral floor was perforated 
by the pus, and urine passed freely through 
the sinus. I injected a 15 per cent, solu- 
tion of papoid, of the formula above given, 
allowing it to remain in the cavity about 
10 to 15 minutes. The patient described 
the sensation at the time, as though many 
mosquitoes were stinging the sac walls. 
I cleansed the cavity with peroxide hydro- 
gen solution as before. In a day or so, the 
abscess closed and remained so for ten days ; 
it then had a slight discharge of pus, but 



an injection of peroxide hydrogen was fol- 
lowed by permanent closure of the sinus. 
This treatment was given three or four 
months ago. 

The prompt arrest of this abscess from 
a single injection of an alkaline 15 per 
cent, solution of papoid, greatly surprised 
me. The cure cannot be attributed to per- 
oxide or hydrogen, as this had been used 
for months with favorable, but not cur- 
ative results ; employed, after the papoid, 
it simply, or mainly oxidised the debris or 
digested pyogenic membrane, facilitating 
its removal. 

Had I employed the papoid and been 
aided by rest to my patient, I am confident 
that I could have cured the case, probably 
several months earlier. 

127 E. Ninety-third St. 



THE TREATMENT OF PERITYPHLITIS. 

Dr. Vollert describes (Deutsch. Med. 
Woclmisclir . , No. 33, 1891) the treatment 
pursued in this affection at the clinic of 
Notlmagie. In recent cases, leeches 
(about ten) are placed over the seat of in- 
flammation. The leeches are supplemented 
by the ice-bladder and cold cloths. If the 
cold is inconvenient to the patient, then 
poultices are employed. If the resorption 
by the exudation is delayed, inunctions of 
green soap or iodoformized collodion, with 
tincture of iodine, equal parts, is applied 
to the part. The diet is, of course, regu- 
lated. Pain is controlled by morphine. 
After subsidence of the inflammation, dur- 
ing the period of convalescence, rectal in- 
jections are given, in case no spontaneous 
alvine evacuation occurs. The enemata 
may be aided by Carlsbad salts. In invet- 
erate cases of peri- and paratyphlitis, where 
the exudation is not resorbed, massage and 
warm poultices are especially serviceable. 
An operation in perityphlitis is only indi- 
cated when an abscess is positively shown 
to exist. The cases most favorable for an 
operation are those where the exudation is 
circumscribed and encapsuled. It has 
been frequently observed, under proper 
treatment, that even large accumulations 
of pus have been resorbed. When peri- 
tonitis occurs as a complication, the prog- 
nosis is always more grave. When the 
vermiform process is perforated, it is best 
resected, unless it is attached to the neigh- 
boring intestines. — Wiener Med. Presse. 



July 2, 1892. 



Communications. 



THE ARTIFICIAL FEEDING OF 
INFANTS.* 



By CHARLES S. SHAW, M. P., 

PITTSBURG, PA. 



The proportion of artificially fed infants 
to those suckled by the mother, or wet 
nurse, in large cities, is variously esti- 
mated to be from ten to twenty per cent. 
As these estimates are based solely upon 
individual observation they necessarily 
differ widely because of the various condi- 
tions of environment that determine the 
method of feeding. Broadly, it may be 
said, that in the higher social scale the in- 
fant is more likely to be deprived of its 
natural nourishment. My own experience 
would place the proportion of artificially 
fed infants at not less than ten per cent. 
This refers only to infants who are fed 
exclusively in this manner; the propor- 
tion would be much larger if it included 
those in whom, because of a deficiency in 
the quality or quantity of the mother's 
milk, some artificial adjuvant is necessary. 
The proper feeding of infants artificially 
is a subject that may well engage the at- 
tention of medical men, for it may be 
safely asserted that the number of children 
properly so fed is, unhappily, very small. 
It is needless to refer to the disasters that 
attend the bottle-fed baby ; they are too 
familiar to demand anything more than a 
passing notice. The statement of Holt 
may be quoted, however, as a general in- 
dex of infant mortality under these condi- 
tions. Of 1,943 cases of fatal diarrhoeal 
disease, 97 per cent, were artificially fed. 

With the maternal method of feeding 
constantly before us as a model, it would 
seem that a sufficient substitute ought 
not to be difficult to obtain, but in spite 
of the apparent simplicity of the problem 
it has not yet been entirely solved, and 
until very recently hardly any progress 
whatever has been made towards its solu- 
tion. There is, however, a vast improve- 
ment in the artificial feeding of infants in 
the last two years; and the improvement 
is due, like most recent advances in medi- 
cine, to a recognition of the all-pervading 
influence of bacterial life. The investi- 
gations of the bacteriologist, which have 
so enlarged the power and scope of surgery, 

* Read before the Allegheny County Medical 
Society, May 10, 1892. 



which promise so much in the treatment 
of disease, have also had a most salutary 
effect upon the subject under consideration. 

In dealing with this question of artificial 
feeding, it is evident that we should en- 
deavor to approximate the maternal and 
natural method as closely as possible, in 
the composition of the food, and the quan- 
tity, the frequency of feeding and the 
method of administration. 

. Practically, we have but one substitute 
for the mother's milk, that is the milk of 
the cow. Goat's milk, asses' milk and 
mare's milk have been suggested and 
recommended, but it is evident that their 
usefulness is very restricted. The legion 
of prepared foods in the market may be 
dismissed without notice. They are all 
defective in composition and at most can 
be used only as adjuvants to a diet whose 
basis must be milk. The milk at the 
command of the consumer in a large city is 
that which we must use. Of course it 
goes without saying, that the fresher and 
purer the milk the better, but with the 
modern method of treatment, the milk in 
the hands of the dealer is sufficient, so the 
care and the expense often futile too, with 
which the anxious parent sought out 
peculiar excellencies in the milk for the 
child are now largely removed. The en- 
deavor is to make a food of this milk that 
will resemble the mother's milk as closely 
as possible. 

The average of the analyses of human 
milk, taken from Rotch's article in the 
Cyclopaedia of Diseases of Children is: 
water, 87-88 parts; solids, 12-13 parts. 
These solids are: fat, 4 parts; albumin- 
oids,. 1 part; milk sugar, 7 parts; ash, .2 
parts. Cow's milk shows by the same 
authority, practically the same proportion 
of water and solids, the solids are : fat, 4 
parts; albuminoids, 4 parts; milk sugar, 
4 parts ; ash, . 7 parts. Here we see the 
same amount of fat in each, but the cow's 
milk contains four times as much albumi- 
noids, a little more than one-half as much 
milk sugar and more than three times as 
much ash. Evidently if we dilute the 
cow's milk with water till the albuminoids 
are the same in each, we will have only 
one-fourth as much fat, a little more than 
half as much sugar, while the ash will be 
nearly the same. Then by the addition of 
fat and milk sugar in the proper quantity 
to the diluted cow's milk, we make a mix- 
ture very closely resembling the mother's 



22 



Communications. 



Vol. lxvii 



milk. But the cow's milk, as we find it 
in the market is acid, while woman's 
milk is invariably alkaline. To remedy 
this we add lime water to the mixture, 
and the result is a compound that seems 
to be almost identical, chemically, with 
human milk. For the preparation of 
8 oz. of the mixture, as given by Rotch, 
take water, 3 oz. ; cream, 2 oz. ; milk, 1 oz. ; 
lime water, one-fourth strength, 2 oz. ; milk 
sugar, 33/% drams. One of the essential 
differences between cow's milk and woman's 
milk, that is removed by this dilution, is 
the character of the curd. Undiluted 
cow's milk coagulates in hard and large 
curds, while the curd in woman's milk is 
very light and fine. The dilution of cow's 
milk, with four parts of water, reduces 
the curd to about the same as that of 
woman's milk. The mixture resembles 
closely the old Meigs' mixture that was so 
popular in Philadelphia a generation ago. 
In composition, appearance, taste and re- 
action, it is almost a perfect imitation of 
human milk, but there is still a most im- 
portant difference — the mother's milk is 
sterile ; the mixture is not. It is the ster- 
ilization of the artificial food that is the 
great advance in modern infant feeding. 
The experience of the nursery long ago 
taught that boiling the milk made it ' 1 keep 
better," and rendered it more acceptable 
to the infant's stomach. Reason would 
suggest that raw milk is the most natural, 
and therefore the better food for the child ; 
and Raudnitz has demonstrated that boil- 
ing the milk lessens its nutritive value, 
but in spite of these objections the boiled 
milk was preferred. The reason for this 
preference is that boiled milk is sterilized, 
and sterilization is of more importance 
than comparative nutritive value or diges- 
tibility. The reason for the well-merited 
popularity of condensed milk may be found 
in the same fact. Condensed milk, though 
a very imperfect food, chemically, is more 
or less sterile, and this compensates for all 
its short-comings. Now, if we sterilize 
the mixture above described, we have 
counterfeited the mother's milk in every 
essential particular, and have, if not the 
ideal food, at least a very satisfactory one, 
and the best at present attainable, This 
is done by heat. The most convenient 
way is by subjecting the mixture to a steam 
bath for 20 or 30 minutes, though any 
other method of thorough heating will an- 
swer. The only requisite is that the mix- 



ture shall be heated to a temperature of at 
least 212°, and kept at that heat for 
20 minutes or more. The vessel con- 
taining the mixture may be placed 
in a water bath and heated, or a 
steam sterilizer may be improvised with 
the kitchen utensils known as a collander 
and a pot for boiling water. It is, how- 
ever, better both for efficiency and conve- 
nience to use some apparatus designed 
for the purpose. Various forms of sterili- 
zers are on the market, and they may be 
equally good, but my experience has been 
limited to that known as the Arnold Steam 
Sterilizer, with which you may be familiar. 
It consists of an evaporating pan surmount- 
ed by a steam chamber, which holds a rack 
containing a number of 7-oz. graduated 
bottles. It is made of tin and is inexpen- 
sive. In using this apparatus the child's 
food for the day is prepared when the 
milk arrives in the morning. When mak- 
ing the mixture the lime water should not 
be added until after heating. Otherwise 
the food will have a straw yellow color, 
and the taste will not be as pleasant, 
though the nutritive value and wholesome- 
ness are not impaired. Sufficient of the 
mixture, without the lime-water, for each 
nursing is put into each bottle, and the 
whole sterilized by 30 minutes' steaming. 
The proper quantity of lime-water is then 
added to each bottle, the neck of each is 
stopped by a plug of clean cotton, and as 
required they are used. In this apparatus 
the sterilizing bottles are used as nursing- 
bottles, and very excellent ones they make. 
The plug of cotton is removed, the rubber 
nipple adjusted, and the mixture heated 
to about 100° in warm water. Any food 
remaining in the bottle after the infant 
has satisfied its appetite, is thrown out. 
This use of the bottle is not only a great 
convenience, but it also removes all neces- 
sity for disturbing or handling the mixture 
after sterilizing, and renders subsequent 
contamination of the food improbable. 

The quantity of this sterilized mixture 
to be given to the child at each feeding de- 
pends, of course, on the size and vigor of 
the infant, and its digestive capacity. 
Biedert's law is two-and-a-half ounces of 
the food to every pound weight of the child 
in 24 hours. During the first three months 
the babe may be fed every two houos dur- 
ing the night. This would make ten feed- 
ings in the ' twenty-four hours, and, allow- 
ing one-and-a-half or two ounces at each 



July 2, 1892. 



Society Reports. 



23 



feeding, would amount to a pint or a little 
more of the mixture. There is always more 
likelihood of over-feeding than of under 
feeding. As the child grows the quantity 
of the food should be increased and the 
intervals between the feeding lengthened. 
At six months the child may be taking 
four or four-and-a-half ounces of food at 
each feeding, and a total of two-and-a-half 
pints in the 24 hours. 

If the sterilized bottle is not used in 
feeding the child, the best substitute is the 
ordinary nursing bottle, or a common 
prescription vial of four or six-ounce capa- 
city. This bottle is surmounted by the 
common rubber nipple or teat. As found 
in the shops the perforations in this rubber 
nipple are frequently too minute, and 
should be enlarged. In the selection of the 
nipple cares hould be taken that it is neither 
too hard and unyielding, a common fault 
with those made of white rubber, nor so 
soft and flaccid that it will collapse, as 
some of the black rubber and red rubber 
ones do. The worst apparatus is probably 
that arrangement with the long rubber 
tube, so popular with lazy and ignorant 
nurses, and to be had at all drug stores. 
It is a device worthy of the invention of a 
Herod, and its sale should be prohibited. 



NERVOUS AND MENTAL DISTURB- 
ANCES FOLLOWING THE EXTIRPA- 
TION OF BOTH TESTICLES. 

M. Weiss (Wein. Med. Press., 1890) 
reports the case of a man fifty-four years 
of age, in whom a series of grave nervous 
symptoms occurred, shortly after the re- 
moval of both testicles for tubercular 
disease. This condition manifested itself 
by great mental and physical restlessness, 
agitation, palpitation of the heart, gastric 
crises, profuse perspiration, melancholia, 
syncope, etc. The author noted the simi- 
larity of these symptoms to those observed 
in women at the menopause, or after the 
removal of the ovaries. 

He ascribes these disturbances to the 
absence of the normal secretions from 
these glands,, which from the experiments 
of Brown- Sequard seem to have a marked 
tonic effect upon the nerves. The re- 
moval of this stimulant, he believes, 
results in a general nervous depression, as 
in cases where other habitual stimulants 
are suddenly suspended. 



Society IReports, 



ALLEGHENY COUNTY MEDICAL 
SOCIETY. 



Scientific Meeting, May 10th, 1892. 

J. C. Lange, M. D., President, in the 
Chair. 

CLINICAL NOTES ON A CASE OF HYSTERIA 
IN A BOY EIGHT YEARS OF AGE. By 

Dr. Samuel Ayres. (See page 18.) 

Dr. Charles S. Shaw read a paper on 
Artificial Feeding of Infants. (Seepage 21) 

DISCUSSION. 

Dr. Green: I am satisfied that every 
physician who has been so unfortunate 
as to engage in the treatment of children 
brought up on these diets, has a task be- 
fore him. I have in numerous cases re- 
sorted to almost any or every method that 
I could find, preparing different foods in 
different manners, and am sorry to an- 
nounce in many instances utterly failed in 
the end, but I have been successful very 
often in the feeding of a child on artificial 
diet, and I feel free to state while I am 
not wedded to any particular food or any 
particular manner of preparing food, I be- 
lieve the condensed milk is very good and 
possibly proves successful in a larger number 
of cases than any other single milk diet that 
is artificially applied or given. I agree 
with Dr. Davis; I think it is well to examine 
the cow as well as the baby and food. I 
think, without looking to all these factors 
in the case, we many times fail, and if we 
fail to find a sufficient quality of food, and 
if we fail to find proper digestion of the 
food given to the child, by examining the 
different points or factors in the case, we 
often can arrive at the preparation of a par- 
ticular food for a particular case. I think 
Dr. Kcenig's remarks were well placed. I 
feel that many times it is not the food ; it 
is the stomach. 

Dr. Lange. There seems to be a little 
diversity in the argument. The title of 
Dr. Shaw's paper was infant feeding, and 
although that is very hard to consider with- 
out considering some of the diseases, still 
it seems the discussion of diseases of in- 
fancy has got the upper hand. No one 
will claim that any food will prevent chol- 
era infantum, " summer complaint;'' that 



24 



Society Reports. 



Vol. lxvii 



if we had an ideal food that summer com- 
plaint would be banished from the land. 
It would probably be banished no more 
than other diseases will be, even under the 
best sanitary arrangements. It seems to 
me every doctor ought to have a standard 
as to infant's food. Now it has been said 
that it has often happened that infants 
would be fed from one cow and then 
another cow and a third cow, nursed by 
one wet nurse, and two, and three and to 
the number of five, but it must be remem- 
bered the period at which the fifth nurse 
nursed the child is not the same as the 
first, second or third did. The conditions 
of the stomach play the most important 
part and not the nurse. It has happened 
to me in my time, to have three infants 
who, we became convinced, could take ab- 
solutely nothing into the stomach: they 
probably could not have taken the ideal 
food if we had had it. These three in- 
fants were deprived of all food and were 
only anointed, one for a period of 
three weeks, with almond oil, oil of 
sweet almond, and the infants received 
nothing into the stomach but a lit- 
tle water and recovered and grew 
strong under that treatment, afterwards 
taking the milk well, which formerly disa- 
greed. Now, the point I desire to make 
is, food, even if it is the best, is not always 
acceptable to infants. Then, as I under- 
stand it, shipping the milk, skaking the 
milk, driving the milk in the sun and 
canning the milk, can do it no harm if it 
is sterilized. It is not the heat that spoils 
it, but the bacteria that are in it. So, if 
it it were sterilized, it might be shipped 
around the world and come back as good 
as it was. That is a strong argument for 
sterilization, but we should have a stand- 
ard of the best infant's food, irrespective 
of differences that may exist between 
mothers and cows. The same differences 
generally exist in every piece of meat that 
we all eat. Further, it has been said that 
it would be beneficial to add a digestive 
ferment, as for instance, pepsin. Now, 
pepsin is getting to be old, and I think 
the majority of you will agree with me if 
you studied it as close as I have, that it is 
a substance which is entirely useless. I 
do not believe a physician ever got any 
result from it, unless he had used along 
with it the important factor, hydrochloric 
acid, and I can promise every gentleman, in 
cases of gastric disturbances, if he will 



use pepsin without hydrochloric acid, and 
then use the acid without pepsin, the last 
will bear much better fruit than the first. 

Dr. Shaw: Mr. Chairman, my con- 
ception of this subject was an average 
one, not the proper artificial food for any 
particular infant, than demands any parti- 
cular care, not a food for an infant of ab- 
normally weak digestive ability, but for 
the average healthy infant, an average 
food, as has been suggested, a sort of 
standard. Now the statement has been 
made that there is a great change in the 
mother's milk at different periods from 
the time of the birth of the child, conse- 
quently a standard artifical food that does 
not also vary, falls short of perfection. It 
does probably fall short of perfection, but 
the fact is, there is no practical difference 
in the composition of the mother's milk 
from the time of the beginning of lacta- 
tion until the end of it. There are con- 
stant trivial differences brought about by 
indigestion in the mother — fatigue, un- 
usual emotions, etc. Any of these things 
will involve the character of the milk to a 
certain degree, but they will not often in- 
volve it sufficiently to make any difference 
to the child; and the woman who has 
weaned a child may take the position of 
wet nurse, and the chances are will nourish 
it better than any artificial food. The 
changes that take place in the cow's milk 
have been said to be more important chem- 
ically than bacteriologically. There can 
be no such distinctions made, for bacter- 
ial growths always produce chemical 
changes. 

The fact that condensed milk has been 
in the hands of some gentlemen particu- 
larly good, is only an endorsement of ster- 
ilization. It is evident to my mind that 
sterilization is not properly understood by 
some gentlemen, and when " sterilized 
milk v acted as a poison it had not been 
properly sterilized. Sterilization means 
more than boiling the milk. It means 
making it sterile and keeping it sterile. 
The milk as it comes from the cow is 
sterile. It is absolutely impossible to keep 
it sterile for any length of time in the 
marketable article of milk. It becomes 
necessary to sterilize it, and that can only 
be done just before the feeding of the 
child. 

It is a fact that some children will thrive 
on almost any food ; a fortunate fact. I 
know of children that from a very early 



July 2, 1892. 



Selected Formulce. 



25 



age, two or three months, have been fed 
almost exclusively on boiled barley. It has 
been often said that infants would not 
digest starch, but sometimes they will, 
though it is evident that starch is not as 
good a food for children as milk. The 
probable reason for the digestion of starch 
in the absence of a proper amyloid digestive 
apparatus is the mucus of the stomach and 
the intestines. The suggestion of one 
gentleman as to the time of putting the 
lime water in the milk, I do not think it 
calls for any .particular discussion. It is 
to my mind only a matter of convenience. 
It is only important that it be put in. 
Infant's food's on the market, in my ex- 
perience, have not been satisfactory. Those 
of them that are used with most satisfac- 
tion are used with milk, and the milk that 
is added to them, and the boiling that is 
usually directed to be done when making 
the mixture, makes a good food, because 
it is sterilized milk. Some of them have 
elements of nutrition that are suitable to 
the digestive capacities of an infant, but 
many have not. I have had a very an- 
noying but instructive experience recently 
in the Rosalia Foundling Asylum. We 
have had constantly in charge from fifty to 
sixty infants under ten months old. About 
one-half of these children were fed on 
bottled food. The opportunity was ex- 
cellent for the trying of a great many arti- 
ficial foods, and we tried carefully, and 
with the help of skilled nurses and asis- 
tants, almost all the foods in the market, 
and none of them were satisfactory. The 
sterilized milk as prepared by Dr. Botch's 
formula certainly suited these children 
best. I am satisfied that where it fails in 
a healthy infant the cause will be that it is 
not properly prepared and sterilized. 



Selectefc formulae. 



THE SCARLATINAL BUBO. 

Drs. Combemale and Lamy have found 
in a case of cervical adenitis, of scarlatinal 
origin, going on to suppuration, that the 
pus, while entering such micro-organisms 
as streptococci and staphylococci, is not 
virulent. The microbes appear dead, or 
are at least deprived of the power of repro- 
duction on nutrient media. Their obser- 
vations lead them to believe that these mi- 
crobian agents act more through their tox- 
ines, which call forth an abundance of 
leucocytes. — Bulletin Med. du Nord, Jan- 
uary 8, 1892. 



ACUTE CORYZA. 

Dr. Hayem, in the Union Medical, 
recommends the following inhalation in 
recent cases of acute coryza : 

TV Acid, carbol. pur 5.0 grammes. 

Ammon. liquid 5.0 

Aquae 15 

Alcohol 15.0 

M. 

A few drops of the solution should be 
poured on blotting paper and inhaled. It 
will be found to act pleasantly and give 
relief in the majority of cases, while in 
some it acts as an abortive. The follow- 
ing snuff is also recommended : 

T>, Bismuth subnitri 6.00 grammes. 

±X Benzoin pulv 6.00 

Acid boric, pul 4.00 " 

Menthol 0.2 " 

M. 

Vaseline and subnitrate of bismuth in 
equal parts will be also found a valuable 
application. 

AN ANTISEPTIC SOLUTION FOR VAG- 
INAL INJECTIONS. 

V Union Medicate states in its issue for 
February 29, 1892, that the following is 
used by Sunar for the purpose of render- 
ing the vagina antiseptic : 

T> Beta-naphthol, 5. iv. 

AjJ Alcohol, 5 xxx. M 

Sig.— Make into solution and add a teaspoonful to a 
quart of water which has previously been boiled and fil- 
tered. 

This mixture is then given as a vaginal 
injection, cold or hot, as the case may re- 
quire it. 

TURPENTINE IN iCTERUb. 

Dr. Carceau [La Semaine Medicate, ~No. 
12, 1891; Lo Sperim»ntale, No. 23, 1891) 
has recently used the essential oil of tur- 
pentine in all forms of icterus with hem- 
orrhages and albuminuria, as Weil's dis- 
ease, bilious fever, haemoglobinuric fever, 
as well as yellow fever. He administers it 
as follows : 



Ozonized oil of turpentine, gms. 10. 

Liquid vaseline gms. 36. 

Inject subcutaneously. 



The same quantity may be given in cap- 
sules, of which some sixty may be taken 
within thirty- six hours, thus taking two 
or three every half hour. By this means 
he has been able to cure the most severe 
cases of icterus accompanied by great al- 
buminuria and convulsions. 



26 



Selected Formulae. 



Vol. lxvii 



BRONCHITIS IN CHILDREN. 

Dr. Hare gives the acute stages of bron- 
chitis in children : 

T>, Tr. aconiti gtt. xij. 

J-X Syr. ipecac. f. Sssj. 

Liq. potassii citratii q. s. ad. f . 5iij. 

M. Sig.— One teaspoonful every three hours. 

For the latter stages : 

O Ammonii chloridi 5j. 

-LX Ext. gly cy rrhizse fi f . 3iv. 

Aquae dest .q. s. ad. f . Siij. 

M. — Sig.— One teaspoonful three times a day. 



ARABIAN BALSAM 

A good formula for Arabian Balsam is 
as follows : 

T> Take of 

-IX Oleum gossypium 15 ounces. 

Oleum origani 1 ounce. 

Oleum terebinth 4 drams. 

Mix. 

S. W. Rogers. 

Harwich, Mass. 



HEART PAINS. 

The formula which Dr. Liegeois especi- 
ally recommends is as follows : 

T> Tinct. piscidee erythringe gm. 60. 

-LX Tinct. verat. virid., 

Ext. aconiti rad. ale aa. gm. 15. 

S. : 30 drops morning and night. 

INJECTION FOR GLEET. 

T>. Hydrarg. bichlorid gr. %. 

-LX Zinci sulph. carbolat — 5 ss. ~ 

Acid boric 5 jss. 

Liq. hydrogen peroxid fg iv. 

Aquae destillat f g vj. 

M Use injection in the mornin« and evening. 

Dr. A. Hewson - , College and Clinical 
Record. 



R 



BALANITES AND BALANO POSTHITIS. 
During the stage of inflammation: 

Sodii boracis 5v 

Aquae Bullientis gviii 

M. ft. Lotio 



Sig. Retract the prepuce and cleanse thoroughly 
with the lotion. While still wet apply. 
Bismuthii subnitratis 



R 



Sig. Dust plentifully over and around the glans and 
then pull the prepuce forward to its natural position and 
allow it to remain thus covered for twelve or twenty-four 
hours, when the treatment can be renewed if necessary, 
daily. 

To prevent relapses wash the part two or three times a 
week with the borax lotion. 

Julias A. Faisost, M. D. 
Mount Olive, N. C. 



TREATMENT OF DIPHTHERIA IN PARIS. 

The following treatment of diphtheria 
in children is much advocated at present. 
The room is steamed with a solution as 
follows : 

Phenic acid 3 ij. 

Solicylic acid 5 iv. 

Benzoic acid i jss. 

Alcohol g iv. 

A ta'nespoonf ul is put into a quart of boiling water and 
renewed every three hours. 

As a local application : 

Camphor 5 v. 

Castor-oil 5 iv. 

Alcohol 5 iij. 

Phenic acid 5 j. 

Tartaric acid 3 i. 

— Medical Press. 



OUABAINE. 

J. Sailer (Therap. Gaz., November and 
December, 1891), who has investigated 
the physiological action of ouabaine, has 
arrived at the following results: — 1. 
General action: On dogs and animals 
capable of vomiting it acts as a powerful 
emetic ; it excites defsecation, perhaps by 
paralysis of the sphincters; it is probably 
a diuretic, at least it always causes urina- 
tion in animals to which it is administered ; 
it does not affect body temperature. 2. 
On the circulation, ouabaine produces first 
a slowing of the heart from stimulation 
of the cardio-inhibitory mechanism, per- 
haps also from direct action on the heart 
muscle. At the same time there is a 
vasomotor spasm sufficient in most cases 
to overbalance the slowed heart rate, and 
to produce rise of blood pressure. Next, 
there occurs sudden and great increase in 
pulse rate from paralysis of the vagi, and 
still further rise in blood pressure, with 
continued vascular spasm. Lastly, the 
heart itself is paralyzed, and death ensues. 
3. On respiration, the drug probably acts 
by stimulating the respiratory centre, but 
only to a slight extent; respiration gener- 
ally continues for some time after the 
heart has ceased beating. 4. On the nerv- 
ous system (a) the drug diminishes and 
finally abolishes reflex action by paralysis 
of peripheral sensory nerves and nerve 
trunks ; (b) motor nerves seem to be only 
exceptionally paralyzed, unless the drug 
be applied direct to them; (c) on the 
central nervous system the drug appears 
to exert no action. 5. Muscles are para- 
lyzed by a direct action of the drug on 
their tissue. 6. On the dog the drug acts 
as a very powerful local anaesthetic when 
applied to the cornea in weak solution, 
and this without causing any inflamma- 
tion, in man, however, it has been stated 
to produce much irritation when thus 
applied. 



July 2, 1892. 



Editorial. 



27 



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Xeabing Hrticles* 

THE ANATOMY OF THE TONSILS, 
WITH REFERENCE TO THEIE 
SURGICAL TREATMENT. 

Although we have but little knowledge 
of the physiology of the tonsils, we have 
practically to consider them as causes of 
many disturbances of function, as well as 
being the seat of acute and chronic inflam- 
mation. Their influence in the pathology 
of the naso-pharynx is especially great, 
and able observers have shown that many 
obscure troubles affecting these parts can 
often be traced to an abnormal condition 
of these organs. Consequently, it is im- 
portant that we should have correct ideas 
of their anatomy, in order that we can in- 
telligently treat them when they are the 
seat of disease. 

The profession is indebted to Dr. Har- 
rison Allen for a recent and very valuable 
paper upon this subject, which is entitled, 
"The Tonsils in Health and Disease,'' 
in which that able authority on diseases of 
the throat gives a more satisfactory ac- 
count of the gross anatomy of the tonsil 
than is found in any of the standard text- 
books. The intent of his paper is best de- 
scribed in his own words (Amer. Jour. 
Med. Sciences, p 92, 1892.): "The object 
of this paper is to harmonize the descrip- 
tions of the normal tonsil with the ac- 
counts of its morbid conditions. It is an 
axiom in medicine that the best basis on 
which the clinical study of any organ can 
rest is on exact knowledge of its 
structure. I will endeavor to show that 
our conceptions of the tonsil are not 
in conformity with this axiom. Some 
of the descriptions of the tonsil have been 
drawn up from hypertrophied glands, 
some from atrophied glands, while the 
terms used by anatomical and clinical 
writers are often at variance with one 
another. I cannot recall any other struc- 
ture in the body of which this can be said. 
This confusion does not arise from lack of 



28 



Editorial. 



Vol. lxvii 



knowledge, for numbers of valuable papers 
have been written on the tonsil and its 
plan is understood. But the description 
of the mass is conventional and clinicians 
have not seen fit to depart from antiquated 
and often quite inaccurate methods of ex- 
pression." 

In the above quoted paragraph the au- 
thor clearly indicates what is actually the 
case, when the various standard authorities 
upon anatomy are referred to, viz., that 
their descriptions of the structure of this 
clinically important organ vary very much 
from each other, and that, as a conse- 
quence, we do not possess clear ideas re- 
garding the normal structure. 

The fact is, according to Dr. Allen, 
there is considerable normal variation in 
the form of the tonsil, while its general 
morphological plan remains more or less 
constant, except in those cases in which it 
is completely masked by disease. The 
form of tonsils most frequently seen by 
him he describes as follows : ' ' The varia- 
tion which I have most frequently seen is 
a rounded or elliptical mass — of which the 
vertical is the largest diameter — placed in 
the tonsil space a little above the level of 
the tongue. The organ is slightly com- 
pressed from before backward, and con- 
sists for the most part of a pocket or crypt 
— whose walls are greatly thickened — 
directed downward. The anterior wall of 
the pocket is covered with mucous mem- 
brane which is every way similar to that 
lining the pharynx, along the side of which 
it sometimes extends as far as the tip of 
the epiglottis. Above the mouth of the 
pocket lies a mass which constitutes the 
' tonsil ' of common language. This alone 
is cryptose." From this it will be seen 
that the almond-shaped body, commonly 
described as the tonsil, is really but a por- 
tion of the tonsil. In addition to the 
foregoing, Dr. Allen describes a (i second 
smaller, somewhat nodular body Avhich is 
quite distinct from the foregoing," situ- 
ated higher up and slightly back of the 



palato-pharyngeal fold, which he terms 
the " velar tonsil." The middle portion 
of the tonsil, situated above the main 
pocket as described above is very com- 
monly, according to Allen, channelled by 
" numerous communicating passages," 
especially seen in the tonsils of children 
and which often run deeply into the gland. 
Haller, Luschka and Asverus also describe 
these slits and fissures, which in the adult 
are obliterated by hypertrophy of the con- 
nective tissue elements of the gland, with 
atrophy of the lymphatic follicles, so that 
the organ is reduced to hard nodular 
masses, which bear no resemblance to the 
original structure of the gland. 

We need not dwell further upon the 
anatomical peculiarities which are so ably 
presented by Dr. Allen, and will refer the 
reader to the original paper. 

Not only must we have a clear under- 
standing of the anatomy of the tonsil to 
successfully treat the organ when it is in a 
diseased condition, but also the changes 
which age effects in its appearance. The 
tonsils are largest in childhood and atrophy 
after the age of 25 years. Their develop- 
ment, Dr. Allen thinks, has some relation 
to the "rate of dental development, and 
the small size of the jaw." Eegarding the 
enlarged tonsils of children, the same au- 
thority lays down the following clinical 
rule for determining whether the enlarge- 
ment is physiological or pathological : ' ' No 
matter how large the tonsil may become* 
it need not constitute a clinical state un- 
less respiration is impeded. If the child 
has nasal respiration, a natural form of 
chest, and roof of the mouth and the teeth 
regular, the tonsils are in a physiological 
condition ; but if there is snoring respira- 
tion, irregular teeth, the habit of mouth 
breathing established, a high, narrow pala- 
tal arch being present, and the child be 
pigeon-breasted, then the enlarged tonsil 
may be said to constitute a clinical con- 
dition." 

When it is necessary to excise the tonsil 



July 2, 1892. 



Book Reviews. 



29 



there is considerable difference in opinion 
and of practice about the procedure; some 
advocate the removal of but a superficial 
layer of the organ, while others claim that 
the best results follow when the whole 
tonsil is removed. The weight of evidence 
is decidedly in favor of partial exsection, 
because it is a more simple procedure, 
the parts heal more rapidly, and it is not 
likely to be followed by such serious haem- 
orrhage as sometimes attends the extirpa- 
tion of the whole organ. 

The dangers of excision of the tonsil for 
acute abscess should not be forgotten, and 
in view of the frequent occurrence of fatal 
or alarming haemorrhage in such cases, it 
should be carefully performed. Allen ad- 
vises that the tip of the left fore-finger be 
inserted behind the tonsil, between it and 
the pharyngeal wall, and that the point of 
the knife be directed towards it. Good 
light and a firm position of the head are 
requisites. 



EFFECT OF MERCURY ON THE BLOOD 
OF SYPHILITICS. 

Bieganski (Archiv fur Dermatologie und 
Syphilis, 24, Jahrgang, 1892), from a re- 
search upon the alteration of the blood in- 
cident to syphilitic infection, concludes 
that the syphilitic poison has no effect in 
altering the number of blood-corpuscles ; 
that it increases the number of white 
blood-corpuscles, particularly the small 
mononuclear lymphocytes. At the same 
time the number of the polynuclear white 
blood-corpuscles dimiDishes. The haemo- 
globin of the blood is distinctly lessened. 
On the administration of mercury, the 
blood count is subject to marked changes. 
These, however, are dependent upon the 
greater or lesser thickness of the blood, 
and are not due to any change or alterna- 
tion in the nourishment of the patient. 
Murcury lessens the number of white-cor- 
puscles, and renders the relation between 
the white and red almost normal. It is 
particularly the mononuclear white cor- 
puscles which are diminished in number, 
the polynuclear cells again becoming more 
numerous. The quantity of haemoglobin 
is distinctly increased by the administra- 
tion of mercury. 



Book Reviews. 



A TEXT-BOOK OF THE PRACTISE OF 
MEDICINE FOR THE USE OF STUDENTS 
AND PRACTITIONERS. By R. C. M. 
Page, M. D. Author of " A Chart of Physi- 
cal Signs of Diseases of the Chest," " A Hand- 
book of Physical Diagnosis of Diseases of the 
Organs of Respiration and Heart;" Professor 
of General Medicine and Diseases of the Chest 
in the New York Polyclinic, etc. 8vo, 578 
pp New York : William Wood & Co. Price, 
$4.00. 

A careful perusal of this admirably con- 
cise treatise convinces us that it will be 
found a useful book for those for whom it 
was written. In these days of rapid progress 
in medicine, with the wonderful advances 
which have been made in the methods of 
clinical instruction, it is most desirable 
that the students who go to the great 
medical centres especially for bedside in- 
struction should possess some reliable 
medium of information to which they can 
refer quickly for any needed points — this 
is the motive which prompted the author 
to compile the present volume; and it 
may truthfully be added, is clearly shown 
in the pages of the book itself. Brevity, 
conciseness, and clearness of expression 
characterize it throughout, while the style 
and arrangement have not been sacrificed 
in order to attain these results. 

The initial chapter upon the normal 
conditions of the chest, followed by a 
digest of the diseases of the heart and 
blood-vessels, is a model of lucidness, and 
presents the essential facts involved in a 
consideration of them, and very little 
more. In the aetiology and pathology of 
aneurisms we notice the failure to mention 
the mycotic variety which Eppinger has 
so well described, and seen by Osier. 
Another important omission occurs in the 
space devoted to chorea, in which only the 
ordinary chorea of childhood is described 
without mention being made of the adult, 
hereditary and senile varieties of the dis- 
ease. In a work of this kind, however, 
it is chiefly important that the main facts 
concerning disease should be untram- 
melled by too frequent reference to un- 
usual or rare conditions, and probably 
many omissions which occur throughout 
the book have been intentional, and, in 
justice, it must be said that but few of 
them are important. 

The chapter on dysentery would have 
been more satisfactory if the amoebic 



30 



Periscope. 



Vol. lxvii 



variety had received attention, and the 
connection between this form and 
liver abscess noted. This condition has 
of late } T ears received considerable study 
in certain quarters and is certainly deserv- 
ing of mention in any work on the prac- 
tise of medicine. 

The author differs from many in advis- 
ing the use of quinine vigorously for the 
first week or two " of typho-malarial fever, 
for according to the investigations of our 
Southern physicians living along the Miss- 
issippi Elver we know that a few maxi- 
imum doses given at the very beginning of 
the disease are just as efficacious, and that 
the further use of this drug is sometimes 
positively harmful. 

One of the best portions of the volume 
is that devoted to the treatment of disease. 
In that connection with each affection the 
treatment is carefully reviewed, and many 
prescriptions of well-known value have 
been added with the idea that they will be 
of service to the young physician. 

In general terms we think that the 
author has been successful in condensing 
in one small and elegantly bound volume 
the best part of our knowledge of practi- 
cal medicine, and that his object " to facil- 
itate clinical instruction and enable both 
physician and student to obtain, in brief, 
the most practical as well as scientific 
view of various subjects treated of in a 
work on medicine " has been attained. 



CANCER AND ITS TREATMENT. By 
Daniel Lewis, A. M., M, D., Ph D., Surgeon 
to the New York Skin and Cancer Hospital, 
etc., Detroit, Mich.: Geo. S. Davis, 

In this new volume of the Physician's 
Leisure Hour Series the author has added 
a most instructive little book. Within the 
limits of 123 pages he has grouped the main 
facts concerning the aetiology, pathology, 
symptomatology, prognosis, and treat- 
ment of the different forms of cancer. He 
does not increase the difficulties attending 
a comprehensive study of this affection by 
the use of many terms, and broadly in- 
cludes under the term cancer all malignant 
neoplasms. The author has also made 
use of cases seen at the Skin and Cancer 
Hospital for purposes of illustration, as 
well as cases from his private practise. 

The opening chapter refers to the medi- 
cinal agents which have proven of some 
value. Among these he mentions Chian 



turpentine, chloride of aniline and pyok- 
tanin. The chapter devoted to the dis- 
cussion of the development of cancer from 
non-malignant affections is interesting. In 
other chapters cancer of special regions is 
dealt with; and some interesting statistics 
are given. Special mention should be 
made of the part devoted to treatment, 
since it is wholly modern, well written and 
in accord with the best principles clinical 
experience has taught us. The brochure 
is an exceedingly creditable addition to . the 
Leisure Hour Series. 



periscope. 



THERAPEUTICS. 



DIURETIN IN INFANTILE PRACTICE. 

According to the observations of Dr. E. 
Demme, Professor of Paediatrics to the 
Faculty of Medicine of Berns, diuretin 
may be administered in the daily dose of 
.50 to 1.50 grammes (7)4 to 22 grains) to 
children of from two to five years old, and 
in daily doses of 22 to -45 grains in chil- 
dren of six to ten years. In infants less 
than a year old the drug is contra-indicated, 
as it easily provokes gastrointestinal irri- 
tation in these young patients. 

Care should be taken in prescribing di- 
uretin, as it is liable to be decomposed by 
certain substances. M. Demme recom- 
mends the following : 

T> Diuretin - . ...gr. xxij 

iy Distilled water M iij 

Brandy gtt. x 

Sugar grs. xl 

M. Sig. To be taken in the course of the 2i hours in 
doses of one tablespoonf ul. 

Dr. Demme's observations have con- 
vinced him that diuretin is a good diuretic 
for children, exempt for the most part of 
all unpleasant influence, and probably act- 
ing on the renal epithelium. 

Under the influence of diuretin. the 
dropsy of scarlatinal nephritis disappeared 
more quickly than by the action of any 
other medicament. It suppresses very 
rapidly the anasarca and serous effusions 
in cases of mitral disease, when the com- 
pensation has been previously established 
by means of digitalis. 

The diuretin was generally well suppor- 
ted and it had no cumulative action. 
However, in one case of generalized dropsy 
in a child of ten years, suffering from amy- 
loid degeneration of the liver, spleen and 



July 2, 1892. 



Periscope. 



31 



kidney, Dr. Demnie has seen a morbilli- 
form eruption with abundant diarrhoea, 
after the injection of 90 grains of diuretin 
in the space of four days. — La Semaine 
Medicate, Feb. 24, 1892, 



PENTAL AS AN ANAESTHETIC. 

Brener, in a communication to the Royal 
Medical Society of Vienna, reports having 
used pental as an anaesthetic 150 times in 
his dental practice. Loss of sensation is 
produced before complete loss of conscious- 
ness. Usually the patient recovers quickly 
and easily. The effect is produced gener- 
ally in one or two minutes, and requires 
ten to fifty grammes. According to Rog- 
ner in the Wien. Med. Pr., 1891, and 
Hollander in Nouv. Rem., 1891, the loss 
of sensation lasts about four minutes, and 
towards the end of the seventh minute 
passes away. There is no vomiting or 
other troublesome symptom during the in- 
halation, nor does headache or sickness 
occur afterward. The loss of conscious- 
ness comes on during the first few minutes 
with complete loss of voluntary movement. 
Rogner considers it the best antiseptic to 
use in minor surgery. In spite, however, 
of these favorable reports, Brener himself 
had a serious accident. A girl who re- 
quired extraction of a tooth was placed 
under the effect of pental. She had only 
taken four grammes when alarming symp- 
toms arose — syncope, apnoea, loss of pulse, 
and dilatation of the pupil. It was neces- 
sary to resort to artificial respiration to re- 
store consciousness. This fact, as Basch 
and Dittel observe, proves that new anaes- 
thetics, and especially those producing 
rapid narcosis, require great care in their 
employment. — Lancet. 



LA GRIPPE. 

Epidemic Influenza, according to Dr. C. 
E. Taylor, Medical Standard, spends its 
force upon the central nervous system — 
especially the spinal cord. The local mani- 
festations are due to interference with its 
functions which produces the frontal head- 
ache, nasal pharyngeal, laryngeal and pul- 
monary congestion, cardiac irritability, 
myalgia, enteralgia and intestinal catarrh, 
priapism with erotic excitement and tem- 
porary paraplegia. Erotic excitement con- 
stitutes a well-marked symptom in the 
earlier period of the attack in a consider- 



able portion of cases. The remedies in 
this disease are ammonium salts and cam- 
phor. By the intelligent use of these, with 
other indicated treatment, the cure is gen- 
erally complete, and complications and se- 
quelae are not likely to occur. The new 
antipyretics should generally be avoided, 
except in very robust subjects and in the 
first few hours of the malady. The first 
remedy usually indicated is ammonium 
bromide, as long as there is much acute 
pain. The next most important is ammo- 
nium salicylate if there be fever alternating 
with chilly and sweating stages. If there 
be torpidity of the liver, the chloride should 
be used. If the kidneys require especial 
attention, the benzoate. If the patient 
cannot be seen often, he suggests the fol- 
lowing, which he has used with satisfaction : 



Acid salicylici 5 ii 

Ammonii carbonatis, q. s. ad neutr., 

Ammonii bromidi 5 ii 

Glycerini. 5 xii 

Ammonii chloridi 5 ii 

Aramonii benzoatis 5 ii 

Lip. ammon. acet 5 xvi 

Aq. menth. pip. q. s 5 xlviii 



M. S.— One tablespoonful in hot milk or water every 
two hours, until relieved, then reduce the dose gradually 
to a teaspoonful, no dose to be taken in less than two 
hours after eating. Should be made fresh when needed. 

This may be beneficially alternated with 
a good camphor mixture. The heavily 
loaded tongue is well met with sodium sul- 
phite. Rest should should be absolute and 
complete, both physical and mental. The 
busy man who keeps at his work as long 
as he can stand, then goes to bed to have 
his correspondence read to him, and to 
dictate replies is virtually committing 
suicide. As between rest and no medicine, 
and medicine and no rest, the influenza 
patient had far better take the former. 



ACTION OF PARAFFIN IC NITRITES ON 
BLOOD PRESSURE. 

Professors Cash and Dunstan have re- 
ported to the Royal Society on this subject, 
their knowledge being derived from ex- 
periments on cats and rabbits. It was 
found that the well-known effect of a fall 
in blood-pressure produced by amyl nitrite 
is due to the direct action of the drug on 
the vascular walls causing the vessels to 
dilate, and not to its action on the vaso- 
motor centre. The experiments which the 
professor made were of two kinds. In the 
first the head was cut off from the circula- 
tion, and amyl nitrite still gave rise to as 
great a fall of pressure as when the head 



32 



Periscope. 



Vol. lxvii 



was included in the circulation. In the 
second series the drug was injected into 
the carotid artery, but prevented from 
reaching the general circulation by appro- 
priate ligatures. The fall of pressure did 
not occur until these ligatures or clamps 
were removed. Experiments were also 
made on man with a view to ascertaining 
the order of activity for various nitrites 
when inhaled, and the result was the fol- 
lowing order: (1) alpha-amyl; (2) beta- 
amyl; (3) isobutyl; (4) secondary butyl; 
(5) primary butyl; (6) secondary butyl; 
(7) primary propyl; (8) ethyl; and (9) 
methyl. All the nitrites produce a fall of 
blood-pressure and an accompanying accel- 
eration of the pulse ; the latter is not so 
marked after intravascular injection as 
after inhalation, and is also less marked in 
cats than in men. The respiration is af- 
fected temporarily' during inhalation in 
various degrees by the different nitrites, 
and permanently by repeated administra- 
tion of the same or different nitrites. 



ON THE ACTION AND USE OF TINCTURE 
OF CALUMBA. 

Nearly 130 years ago, Dr. Percival of 
Manchester (" Essays, Medical and Ex- 
perimental," Vol. II.), drew attention to 
the value of calumba root in diarrhoea, 
and recorded five cases, showing its efficacy. 
He pointed out that the tincture was the 
strongest preparation, and by experiments 
on himself showed that it did not influence 
the circulation. 

Schultz (Therap Monat., Feb., '92) 
publishes a series of observations on the 
use of calumba in health and disease, 
which do little more than confirm the con- 
clusions arrived at by Percival. He notes 
one or two points of practical interest. 
Out of the five healthy people to whom 
he gave a preparation made by extracting 
one part of tiie root with ten of alcohol, 
he found that in one, daily doses continued 
for a week, and gradually increased from 
25 minims to a drachm, were followed by 
stomach catarrh and a slightly relaxed 
condition of the bowels. Eventually there 
was extreme repugnance to the medicine. 
In a second case, the action of the bowels 
became very slightly incresaed by large 
doses of the tincture. In none was the 
circulation affected ; the other three were 
not influenced at all by full daily doses. 
The cases seem to indicate that in some 
even tincture of calumba may slightly dis- 



turb the bowels if continued long in full 
doses. 

Schultz records 14 cases in which tinct- 
ure of calumba seems to have a distinct 
effect in checking diarrhoea and regulating 
the action of the bowels. Even in the 
diarrhoea of phthisis he found it successful. 
He gave it in doses of from 40 minims to 
3 drachms usually once, but sometimes 
twice daily. 



TREATMENT OF SORE THROAT. 

It is now generally admitted and agreed 
that in diphtheria some form of antiseptic 
or at least aseptic treatment should be 
used, but for the simpler forms of throat 
inflammation, and the catarrhal as well as 
tonsillar troubles, which are supposed to 
be caused by cold, the treatment remains 
for certain doctors what it was — that is, 
chlorate of potassium or other gargles of 
an emollient or astringent nature — and 
yet the simple fact that these troubles are 
frequently seen in the same family, and at 
the same time as diphtheritic diseases, 
would seem to indicate a common origin. 
The infectious nature of tonsillitis and 
other simple forms of throat and bronchial 
disease or inflammation seems likely, and 
once this is suspected, if not proved, it 
should lead to trying antiseptic methods 
instead of the old astringents. The 
following is a formula much used in 
France : 

T>, Acid, earbol., cryst. 

J-X Camphor, aa gr. xv 

Glycerini, 

Aquee destill., aa f Sii 

This is painted on the inflamed part three 
times a day. It will be found to have a 
mechanical action as well as an antiseptic 
one. — Archives of Pediatrics, December, 
1891. 



TREATMENT OF BUBOES BY INJECTION 
OF IODOFORMIZED VASELINE. 

Dr. Le Jollec (La Semaine Medicate, 
No. 55, 1891), a physician in the French 
navy, has treated several cases of buboes 
with success by the injection of a 5 to 10 
per cent, solution of iodoformized vaseline 
into the bubo. 



TO REMOVE ANILIN STAINS FROM THE 
SKIN. 

Unna recommends washing first with 
a five per cent, solution of salt in water, 
then with the same strength of hydrogen 
peroxide, and finally with alcohol. 



July 2, 1892. 



Periscope. 



33 



MEDICINE. 



THE DIAGNOSIS AND PROGNOSIS OF 
SYPHILITIC DISEASE OF THE BRAIN. 

Dr. Otto Harmsen has been induced by 
the scarcity of information relating to 
syphilitic disease of the brain to publish 
particulars of nine such cases, which had 
remained under observation for a year or 
more in the Berlin clinic for nervous dis- 
eases. The ArcJiiv. f. Dermat. u. Syph., 
which publishes the account, points out 
that the meagre statistics of this affection 
have often been complained of, more 
especially by Naunyn. The chief symp- 
toms in most instances were headache, 
vomiting, vertigo, facial paralysis, aphasia, 
and hemiplegia. In one case polydipsia 
and polyuria appeared some years after 
the primary infection, and serious cerebral 
symptoms quickly followed. In another 
case the nervous symptoms appeared as 
early as two years after the initial sore. 
Nearly all the cases were cured by ener- 
getic anti- syphilitic treatment, this being 
most marked in a patient never before 
treated with mercury. It should be men- 
tioned that in many instances a tempor- 
ary disturbance of the reaction of the 
pupil was the first and only indication of 
cerebral mischief, as has been pointed out 
by Oppenheim. . . 



ESSENTIAL PAROXYSMAL TACHY- 
. CARDIA. 

Dr. J. W. Brannan, in a paper upon this 
subject, refers to that form of tachycardia 
in which a very great exhilaration of the 
pulse, occurring in paroxysms, was the 
cardinal symptom. The paroxysm might 
last a few minutes, or it might extend, 
without interruption, over a period of 
several weeks. In the intervals between 
the attacks the heart- beat should be nor- 
mal, both in force and in frequency, and 
the individual seemed to be in perfect 
health. There was no history of rheuma- 
tism, nor were any valvular murmurs 
detected. In 4 cases in which an autopsy 
was performed no anomaly was found. 
Dr. Brannan has collected only 2? cases 
of this rare disease. The attacks are 
characterized by extreme rapidity of the 
heart's action, which may attain 250 or 
even 300 pulsations a minute. It is very 
much like that produced by section of the 
pneumogastrics in animals. The pulse 



is usually regular, often not perceptible at 
the wrist, but to be found in the carotids 
and f emorals. The attacks occur suddenly, 
as a rule, and at other times they follow 
some strong mental emotion or physical 
fatigue or effort. The face is usually very 
pale throughout the paroxysm, the pupils 
are normal. There may be moderate 
dyspnoea. Anorexia and constipation are 
present with almost complete insomnia. 
The subjective sensations are variable, and 
include epigastic oppression, pain at the 
precordia and numbness of the left arm or 
general chilliness. The attack ends sa 
abruptly as it began; the pulse dropping 
suddenly from 200 or more to 72 beats per 
minute : There is extreme cardiac disten- 
sion as shown by the area of dullness. In 
discussing the aetiology of the disease, Bou- 
veret has drawn attention to the entire ab- 
sence of hysteria, or neurosthenia in the 
cases collected by him, and there was no 
hereditary neurotic tendency. Of the 25 
cases in which the sex was noted, 11 were 
in males and 14 in females. Over- fatigue, 
either mental or physical, seems to be the 
chief cause of the affection. 



PRECOCIOUS HEREDITARY CEREBRAL 
SYPHILIS. 

Dr. D'Astros {Journal de Medicine, Jan. 
2, 1892) in a communication to the Asso- 
ciation for the Advancement of the Scien- 
ces, spoke on the cerebral localizations in 
the new-born, to which Fournier has al- 
ready called attention. These cerebral 
manifestations present themselves under 
various aspects : syphilitic meningitis (rare 
and ill defined) ; syphilitic arteritis of the 
arteries of the brain (quite frequent) ; gum- 
mata (rare and often during the second 
infancy) ; syphilitic ependymatis or ven- 
tricular syphilis, of which latter the author 
has observed two instances. The onset was 
quite precocious (one month after birth), 
and death took place in less than a month. 
At the autopsy (an acute ventricular hydro- 
cephalus was found with embryonal infil- 
tration in the ependyma and the striated 
bodies. The functional importance of the 
corpora striata for the reflex life of the in- 
fant is perhaps the cause of this localization. 
The cerebral gummata and syphilitic cere- 
bral meningitis and arteritis are relatively 
late lesions, especially the first two ; syph- 
ilids ependymatis is the most precocious 
form and the most characteristic of hered- 



34 



Periscope. 



Vol. lxvii 



itary cerebral syphilis. Its evolution ap- 
pears to bear a relation to the degree of 
infectiousness of the syphilis. It is made 
manifest by a variety of nervous symptoms, 
convulsions, contractures, tremblings, stra- 
bismus, and especially by acute hydroceph- 
alus of rapid development which is charac- 
teristic. 

DOUBLE CONGENITAL ENTROPION. 

G-uibert [Arch d'Ophtal., February, 
1892) reports the case of a female child, 
aged 3, with complete entropion of the 
lower eyelids, the free border with the 
lashes being entirely hidden; in conse- 
quence of the infolding the lids appeared 
thickened. This condition had been no- 
ticed by the mother eight days after birth. 
The eyes had not suffered from the abnor- 
mal position of the cilia, the cornese were 
clear, and there was no conjunctival irri- 
tation. The operative procedure adopted 
consisted in cauterzing along the skin sur- 
face two millimetres from the ciliary mar- 
gin of the lid, and penetrating all the tis- 
sues down to, but exclusive of, the con- 
junctiva. The result was quite satisfactory 
and six months later there was no return 
of the entropion. A point of interest noted 
by the author is, that when applying the 
cautery to the lids, no structure was met 
with representing the tarsal cartilage (so- 
called). The absence of this constituent 
of the lid was looked upon by Panas as the 
probable explanation of congenital entro- 
pion, and Guibert thinks it will explain 
the condition in his patient. There were 
no other discoverable congenital defects in 
his case, and no family history of such. — 
Brit. Med. Jour. 



THE SPECIFIC GRAVITY OF THE BLOOD. 

A fair amount of literature is extant upon 
the subject of the specific gravity of the 
blood, and among those who have contrib- 
uted thereto may be mentioned Schmeltz, 
Landois, Lloyd Jones, Roy, and lastly, 
Peiper, the latter having recently recorded 
some observations to which reference may 
here be made. The specific gravity of the 
blood in healthy human beings varies but 
slightly — 1045 to 1046 — with an average 
which is somewhat higher for men (1055) 
than for women (1053) or children (boys 
1052, girls 1050). In disease the varia- 
tions may be relatively considerable, that 
is, from 1055 to 1068. In nephritis, chlo- 
r. sis, and anaemia, also in maladies asso- 



ciated with much wasting, such as phthisis 
and carcinoma, the specific gravity is low- 
ered, but in febrile diseases, and in condi- 
tions causing marked cyanosis, it is raised. 
The blood of birds is apparently heavier 
(1059 to 1075) than in mau, while that of 
frogs is lighter (1034 to 1053). It is evi- 
dent, however, that not much is to be 
gained by the estimation of the specific 
gravity of the blood in disease, as far as 
diagnostic or therapeutic purposes are con- 
cerned. According to the author, "the 
specific gravity varies considerably in dif- 
ferent persons, so much so, that a specific 
gravity which is normal for one may be a 
sign of disease in another." Under these 
circumstances it would scarcely be possible 
in any given case to say whether an appar- 
ently abnormal record was pathological, or 
the usual physical condition of the patient's 
blood. — Med. Press. 



RECURRENT ERYSIPELAS. 

Critzman {Arch, gen.de Med., January, 
1892) says that erysipelas is distinguished 
from other cutaneous infections by its 
property of extending superficially, and 
hardly ever into the deep and sub- 
jacent layers of the integument. It is 
caused by the streptococcus erysipelatis. 
This micro-organism is, perhaps, identical 
with the S. pyogenes, but the suppura- 
tion produced by the latter cannot be 
identified with the serous inflammation 
produced by the former. It is disputed 
whether phlegmonous erysipelas (a com- 
plex affection) is due to the exalted virul- 
ence of the S. erysipelatis, or is an expres- 
sion of a secondary infection. Erysipelas 
is very rarely phlegmonous from the out- 
set, and suppuration is really a complica- 
tion. The type of recurrent erysipelas is 
seen in the catamenial form. It may 
occur as often as ten, twenty and more 
times. Repeated attacks give immunity 
against symptoms, but not against the 
disease. Critzman relates a case occurring 
in a woman, aged 35, suffering from uter- 
ine fibroid. She had the first attack of 
facial erysipelas at 30, since when she said 
she had an attack nearly every month. 
The one observed by him began with 
shivering. A piece of skin was excised 
by permission of the patient. The culti- 
vation and inoculation experiments were 
successful in demonstrating the micro- 
organism. In sections from the skin the 



July 2, 1892. 



Periscope. 



35 



disease was made out to be a dermato- 
lymph-angitis, and the streptococci oc- 
cupied the lymph spaces and vessels. In 
some of the infective diseases, as enteric 
fever, syphilis, variola, a second attack 
hardly ever occurs, but in others recur- 
rence does happen, only to name ordinary 
tonsillitis. Two conditions only are 
necessary for recurrence: (1) presence of 
the micro-organism; and (2) a suitable 
soil for renewed growth. In recurrent 
erysipelas the streptococcus exists, as is 
shown above. After an attack it loses its 
virulence for a time, but under influences 
not yet understood this virulence may re- 
turn, and with it the recurrence. — Brit. 
Med. Jour. 

NORMAL TEMPERATURE OF THE AGED. 

Kelynack (Manchester) publishes in the 
Medical Chronicle (vol. xv., 1892, No. 5) 
the results of observations on the temper- 
ature of healthy old persons (eighty-two, 
eighty-three, and eighty-nine years of 
age), which tend to show (l)that the nor- 
mal senile temperature, as registered both 
in the rectum and axilla, is very distinctly 
below that of healthy children and adults. 
2. That the rectal or internal temperature 
in old age is almost always higher than the 
axillary, but varying from 0.2° to 1° F. 



SURGERY. 



TREATMENT OF POST-OPERATIVE IN- 
TESTINAL OBSTRUCTION. 

Lucas-Championniere [Rev. de Chir., 
March, 1892) reports five cases in which it 
was found necessary to perform laparotomy 
for the relief of internal strangulation fol- 
lowing operation on the viscera of the ab- 
domen. In the first of these cases the 
symptoms of obstruction were presented 
on the eighth day after ovariotomy, and 
were found to be caused by old adhesions 
of the intestine to a mass of the omentum. 
The primary . operation in three cases was 
for the radical cure of hernia, and in the 
fifth case for strangulated hernia. The 
post-operative obstruction was due in three 
instances to adhesions, and in one to the 
pressure of a large intra-peritoneal effusion 
of blood. All these patients made good re- 
coveries after the second operation. Men- 
tion is made of a case of fatal obstruction 
after an operation for the radical cure of 
hernia, in which, after death, a loop of 
intestine was found to have been strangu- 



lated by a peritoneal band. In cases of 
this kind it is often difficult to determine 
whether the patient be suffering from ac- 
tual strangulation or from simple obstruc- 
tion of the intestine. If it be clear that 
the bad symptoms following operation are 
due to mere obstruction, purgatives, the 
author holds, ought to be administered. It 
is not a rare occurrence for laparotomy to 
be followed by intestinal paralysis with 
faecal retention, the paralysis giving rise 
also to symptoms of occlusion with sterco- 
raceous vomiting. With the view of pre- 
venting this bad result, the author makes 
it a general rule to administer a purgative 
two or three hours after the performance 
of laparotomy, thus following, and, indeed, 
carrying out to a further extent the prac- 
tice advocated by Lawson Tait. Since he 
has adopted this line of treatment he has 
not observed the rise of temperature and 
the symptoms of gastric disturbance which 
so frequently result when the patient is 
subjected tcrthe influence of opium. — Brit. 
Med. Jour. 



CARCINOMA OF THE CARDIAC END OF 
THE STOMACH. 

King {Canadian Practitioner, Feb. 12, 
1892) reports a case, which occurred in a 
woman, 77 years of age, resembles those 
just above referred to, in its latency. The 
patient was a woman who had been ad- 
mitted to a house, not on account of ill- 
ness, but to provide her with a comfortable 
home. Her symptoms were few, and of no 
special moment; her appetite was fair, 
and she never vomited. Two weeks before 
death, however, a severe coffee -ground 
haemorrhage from the bowel occurred, and 
two slight attacks followed in the next ten 
days, and three days prior to death another. 
This was regarded as proceeding from the 
bowel, and so treated ; but she died on the 
third day after. The stomach was found 
to be the seat of carcinoma in the lesser 
curvature at its cardiac end, where there 
was a cup-shaped ulcer, the size of a Mexi- 
can dollar, with sharp, clear cut edges. 
There was no involvement of the oesopha- 
gus whatever. Large numbers of second- 
ary deposits were found in the liver. 
Fagge denies the existence of cancer of 
the cardiac end of the stomach. He thinks 
that all the cases begin in the oesophagus 
and spread thence to the stomach ; but in 
this case there can, in King's opinion, be 
no doubt it was primary. The entire ab- 



Periscope. 



Vol. lxvii 



sence of symptoms, in a case which was 
evidently of long duration, the situation 
of the cancer, and the fact that the imme- 
diate cause of death was haemorrhage, all 
tend to make this case worthy of notice. 



ULCER AND CANCER OF THE STOMACH. 

Dr. E. Kollmar, of the Medical Klinik 
of Tubingen, has an instructive paper in 
the Berl. Klin. Wochensch. on the Differ- 
ential Diagnosis of Ulcer and Cancer of 
the Stomach. The cases related by Dr. 
Kollmar show that neither cachexia, nor 
even a palpable tumor in the epigastrium 
is sufficient to render the diagnosis certain. 
Liebermeister placed the greatest reliance 
on the duration of the disease, and the 
author is at one with him on that point. 
If any gastric disturbance persists for 
years, if there has been vomiting of blood 
for a great length of time, the case is prob- 
ably one of ulcer. Cases have been ob- 
served in which a cancer has developed in 
the cicatrix of an old ulcer, but the author 
considers them so rare that they may be ig- 
nored. In one case a tumor was felt, and 
the history showed illness of thirteen years' 
duration, and cancer was diagnosed. The 
abduction, however, revealed an ulcer that 
had led to attachment to the pancreas, and 
this formed the tumor in the epigastrium. 
The second case was that of a woman with 
a twenty- three years' history of gastric 
mischief. Here, in spite of cachexia, a 
palpable tumor, and absence of hydro- 
chloric acid reaction, a diagnosis of ulcer 
was given, and the patient in fact recov- 
ered. In another case in which advanced 
anaemia with cachexia was present, the 
long duration of the illness led to a diagno- 
sis of ulcer, which was verified at the post- 
mortem examination. 



OBSTETRICS. 



THE TREATMENT OF ASPHYXIA IN THE 
NEWBORN. 

Forest {Medical Record, April 9, 1892) 
describes a method for resuscitating asphy- 
xiated infants as follows: He places the 
child on its face, its head down, and expels 
fluids from the mouth by pressure upon 
the back; the child is then put in a pail 
or tub of hot water in a sitting posture, 
supported by one of the operator's 
hands across its back, its head bent back- 
ward. The physician grasps the child's 



hands with his other hand, carries them 
upward until the child is suspended by the 
arms, leans forward himself and blows air 
into the child's mouth; the infant's 
arms are then lowered, its body doubled 
forward, and its thorax pressed between 
the hands of the physician. Air is thus 
expelled. Especial advantage is claimed 
for this method from the fact that the hot 
water maintains capillary circulation, and 
tends to assist in promoting the action of 
heart. — Amer. Jour. Med. Si. 



CESAREAN SECTION IN EXTREMIS AND 
AFTER DEATH. 

Winckel (Aerztliche Rundschau, No. 5, 
1892) discusses this question, which ap- 
pears to have been taken into consideration 
by political and legislative authorities in 
Bavaria. These authorities have endeav- 
ored to ascertain if it be justifiable to en- 
force upon practitioners the performance 
of Caesarean section on women who die 
during labour. After collecting evidence, 
Winckel finds that the chances of saving 
the child are considerable, the gloomy 
prognosis of Fehling and others being set 
aside by recent experience. The best re- 
sults have been seen when the child has 
been extracted within ten minutes after 
the death of a previously healthy patient 
from flooding, or of a woman ill but very 
shortly before the moment of decease (from 
convulsions of pulmonary embolism, for 
example). In these cases the child was 
delivered at or very near term. Living 
chiidren have, however, often been deliv- 
ered by section and reared after the death of 
the mother from chronic cardiac or pul- 
monary disease. The longest period after 
death when Caesarean section has saved the 
child is from twenty to thirty minutes 
(Pingler, Brotherston). Even when thet 
foetal heart sounds have become inaudible, 
rapid section has saved the child. The 
best success, as might be expected, has been 
obtained in hospitals, where instruments 
are always in readiness. Winckel recom- 
mends Rung's instructions to be followed 
when death during labor occurs in pri- 
vate practice. Alter all, Winckel remarks, 
these cases are still rare, . and therefore laws 
cannot well be framed at present to bind 
practitioners. All cases should be duly re- 
ported, and registration authorities should 
tabulate them especially and with great care 
as to notification of the result. When 



July 2, 1892. 



Periscope. 



37 



the patient dies suddenly in the presence 
of the practitioner or just before his ar- 
rival Cesarean section ought to be done at 
once with any instrument that is at hand. 
When the patient is sinking hopelessly 
from convulsions, apoplexy, etc., prepara- 
tions should be made as complete as possi- 
ble for the performance of Cesarean section 
as soon as the maternal heart ceases to 
b>eat. There remains a grave class of cases 
where, after due consultation, it may be 
deemed justifiable to deliver the child by 
.section, the patient being in extremis. 
Winckel refers to cases of severe dyspnoea, 
anasarca, etc. If the foetal heart sounds 
can be heard, it may seem right to deliver 
the child by Cesarean section, as the very 
slow death of the mother is more certainly 
fatal to the child than her sudden decease. 
— Brit. Med. Jour. 



THE BACILLUS OF ECLAMPSIA. 

The Deutsche medicinische Wochen- 
■sclirift of May 12th contains the announce- 
ment that Dr. Gerdes, first assistant in the 
Pathological Institude to the University 
of Halle, has in a severe case of eclampsia 
succeeded in demonstrating by culture the 
presence of a short bacillus in the liver, 
lungs, and kidneys, and also in the blood. 
The bacillus is extremely virulent when 
inoculated in rats and mice, causing con- 
Tulsions in the latter. In all the animals 
experimented on coma set in, the respira- 
tion became shallower, the body tempera- 
ture became subnormal, and death occurr- 
ed in a short time. In guinea-pigs con- 
vulsions only came on after intravenous 
injections (the jugular vein was selected 
tor the purpose) ; subcutaneous and intra- 
peritoneal injections produced no such ef- 
fect. The bacilli referred to were found 
in great numbers in the lungs, kidneys, and 
liver of patients suffering from eclampsia, 
especially in the form of bacillary emboli, 
the starting point of which was probably 
a primary focus in the placenta. Dr. 
Gerdes promises a preliminary communi- 
cation on the subject without delay. — Brit. 
Med. Jour. 

GYNECOLOGY. 



ICHTHYOL IN DISEASES OF WOMEN. 

Eschen(6fywe&. op Obstet. Meddelelser, 
1891, vol. viii, p. 192) used this drug in 
twenty-five cases. Good effects were ob- 
served in patients with metritis, parame- 



tritis, and inflammation of the ovary, but 
it is admitted that no extraordinary effects 
were observed. 



REPRODUCTION OF THE UTERINE MU- 
COUS MEMBRANE. 

L. M. Bossi (Brit. Med. Jour., Nov. 
7, 1891) gives the results of an experi- 
mental study on the reproduction of the 
uterine mucous membrane after curetting, 
and after the permanent application of 
caustics (Canquoin's paste). He first per- 
formed laparotomy on bitches and then 
scraped away the mucosa in the neigh- 
borhood of the cervix with a Yolkmann's 
spoon ; in other cases the uterus wars open- 
ed along its anterior surface, and differ- 
ent areas were completely denuded with 
a bistoury. In the cauterization cases 
sticks of Canquoin's paste were inserted 
into the corua and allowed to project a 
into the uterine cavity. After a varying 
number of days the animals were killed, 
the parts hardened in alcohol or in Flem- 
ming's solntion, and sections made. 

Staining was done by alum and car- 
mine, also by saffronine. Fifty animals 
were thus experimented on; the results 
in thirty-five only are relied upon in the 
following conclusions : 1. The uterine 
mucous membrane of the dog removed 
from large tracts and in its whole thick- 
ness, is completely reproduced after a time 
together with true glands. 

2. This reproduction may be in some 
cases a slow process from causes not yet 
ascertained. 3. The new epithelium is 
derived from that of the glands at the 
margin of the wound. 4. Finally, the 
reproduced glands arise by proliferation 
of the cells of the new epithelium after 
it has become cylindrical. As regards 
caustics, Bossi comes to the conclusion 
that Tarnier and Polaillon, in their report 
made to the Paris Academy of Medicine 
in 1890, are in error in stating that 
they removed the mucous membrane in 
its whole thickness by caustics, They 
judged only from the expelled eschars 
and not from direct observation of the 
uterus. In all Bossi's cases there were 
incomplete stenosis of the cervical canal 
and complete stenosis of the cornua,and 
even signs of peritonitis. Microscopical 
examinations by the author showed the 
existence of an intense necrotic inflam- 
mation caused bv the caustic, which 
not only destroyed the mucous mem- 



38 



Periscope. 



Vol. lxvii 



brane, bat profoundly altered its gland- 
ular apparatus, so that it became im- 
possible to say whether complete des- 
truction would follow, or whether, a 
restitutio ad integrum being impossible, 
or difficult, grave chronic alteration 
would remain as the result. In con- 
trast to this, in ten cases of removal 
of the mucous membrane, and in twen- 
ty other cases in which the uterus was 
laid open aud the knife used, there 
were never any even incomplete sten- 
osis, and never signs of peritonitis or 
grave inflammation of the uterine walls. 

Accordingly Bossi emphatically asserts 
the superiority of curetting to the use 
of caustics left in situ, as regards both 
immediate and ulterior results. 



PEDIATRICS. 



CHRONIC PERITONITIS IN CHILDREN. 

Henoch [Deutsche med. Woc7ien*c7irift, 
No. 1, January, 1892)does not believe, as 
has been taught by West, that nearly all 
cases of chronic peritonitis in childhood 
are of tuberculous nature. He does not 
see why the peritoneum cannot take on 
a chonic inflammation and cause a serous 
exudation into the abdominal cavity, just 
as the pleura takes on an inflammation. 
He calls particular attention to those cases 
which only show the presence of ascites, 
which may be very large in quantity. 
These cases progress as follows: The chil- 
dren are usually over 3 years of age ; they 
seem to be quite well, do not complain of 
pain, nor is the abdomen tender to pres- 
sure. The only thing that' the parents 
have noticed is an increase of the abdo- 
men. An examination reveals free ascites 
(author has never seen it encapsulated in 
this form of cases). No cause for the as- 
cites can be found in the liver, kidneys, 
or heart. Rarely is it traumatism. Tub- 
erculosis can be excluded in many cases, 
from the general condition of the child 
and its ultimate recovery, although at 
times it may be very difficult to exclude 
this as a possible cause. The finding of 
tubercle bacilli, in the fluid which has 
been withdrawn is often a very difficult 
task, so that, although they are not found, 
we cannot say that the case is not tuber- 
cular, nor does the use of tuberculin help 
us in making a diagnosis. The majority 
of cases affected with this simple form of 



peritonitis are girls. In boys it occurs 
very rarely. This leads to the thought of 
a connection between the affection and 
genital organs, and it has been stated that 
a vulvo-vacinitis, which occurs frequently 
enough in children, may travel up to the 
uterus, thence to the tubes, and so on 
into the peritoneal cavity. These cases 
must be differentiated from a cirrhosis of 
the liver producing ascites, which -can 
only be done after the fluid has been with- 
drawn and the liver then palpated ; and 
from tuberculosis, which, as stated before, 
may be very difficult. The treatment of 
these cases is a purely surgical one. Med- 
icines, puncture, etc., do little if any good. 
The ascites returns almost as fast as the 
fluid is withdrawn. Laparotomy, on the- 
other hand, produces a rapid and perma- 
nent cure in these cases, as it often does in 
tuberculous peritonitis. 



RICKETS IN AUSTRALIA. 

Muskett(Au*tralasia?i Medical Gazette, 
July 15, 1891.)says, rickets has been con- 
sidered a disease of rarity in Australia; but 
that he has found it to be comparatively 
common, though as a rule of mild type. 
Acccording to his description there is 
nothing in the symptoms especially pecu- 
liar. The chief point of interest is the 
fact that this disease is frequently found 
by one who is watching for it, and who 
appreciates its symptoms in a locality 
where it was supposed not to exist. When 
the conditions are favorable the disease is 
sure to appear. 



THE PROPHYLAXIS OF SCARLATINAL 
NEPHRITIS. 

In more than a hundred cases of scar- 
latina seen in the course of six years, in 
in which the patients were for three weeks 
kept upon milk diet, Ziegler has not 
once encountered nephritis as a complica- 
tion. — La Semaine Med., No. 4, 1892. 



HYGIENE. 



A DEFENCE OF TOBACCO-SMOKING. 

It is considered by many that tobacco- 
smoking, Jike ladies' corsets, is indefensi- 
ble on hygienic grounds, and that the only 
reasons for its practice, independent of a 
patriotic desire to aid the State in the con- 
sumption of a dutiable article, and so to in- 



July 2, 1892. 



Periscope. 



39 



crease its revenue — are in the first instance 
the faculty of imitation, then habit, and 
over all caprice. It has fallen to the lot 
of a well-known hygienist of Rome, Dr. 
v. Tassinari, however, to demonstrate that 
tobacco-smoking fulfils a valuable hygienic 
function, viz., that of a powerful disin- 
fectant, making it a prophylactic against 
a number of infective diseases. In order 
to show that he does not stand alone in his 
views, he quotes Drs. Miller, of New York, 
and Vassili, of Naples, both of whom are 
of opinion that tobacco -smoke prevents the 
development of pathogenic germs. A 
large number of independent investigations 
were made by Dr. Tassinari on the influ- 
ence of the smoke of the noble weed on the 
germs of cholera, anthrax, and pneumonia. 

His method of research was to line the 
interior of hollow balls with gelatine con- 
taining the germs of the diseases named: 
tobacco -smoke was then passed through 
these globes for from twenty to thirty 
minutes. The surprising fact was then es- 
tablished that at the expiration of the 
time the bacilli of true Asiatic cholera and 
of pneumonia were completely destroyed, 
whatever the kind of tobacco employed for 
the purpose. The gelatine was absolutely 
sterilized by the tobacco-smoke. The an- 
thrax bacillus was more resistent, however, 
whilst the bacillus of typhoid was scarcely 
acted on at all. It is too much to expect 
that tobacco-smoke will destroy germs al- 
ready domiciled in the system, but it will 
no doubt afford not a little comfort to 
smokers to learn that as far as it goes the 
practice tends to prophylaxis in the case 
of some of the most serious of the infect- 
ive diseases. — Med. Press. 



PASSAGE OF TUBERCLE BACILLUS FROM 
THE MOTHER TO THE FOETUS. 

Birch-Hirschfeld and Schmal have recor- 
ded a case which they consider is the first 
in which it has been definitely shown that 
in the human subject tubercle bacilli can 
pass from the mother to the foetus. The 
patient was a young woman who, shortly 
after the commencement of her first pre- 
gnancy, began to exhibit symptoms of in- 
cipient phthisis ; the disease assumed an 
acute form, and progressed so rapidly that 
the patient died during the seventh month 
of her pregnancy. Immediately after the 
death of the mother the child was removed 
by the operation of Cesarean section. A 



post-mortem examination was made On the 
body of the mother. Advanced tubercular 
changes were found in the lungs, and also 
some miliary tubercles in the liver and 
other organs. The child had been felt to 
move after the death of the mother, but by 
the time the operation had been performed 
it was found to be dead. The thorax was 
at once opened, but the lungs appeared to 
be quite healthy. The body was then re- 
moved to the laboratory, the surface of 
the abdomen washed with perchloride of 
mercury, and the cavity opened by means 
of sterilized knives. No evidences of tu- 
bercle could be found in any of the organs. 
Small pieces of the liver, spleen, and kid- 
ney were removed with sterilized instru- 
ments, and placed in the abdominal cavity 
of two guinea-pigs and a rabbit. One of 
the guinea-pigs died in fourteen days ; mil- 
iary tubercles were found in the peritoneum 
and large omentum. The second one was 
killed about six weeks after inoculation, 
and the same appearances were noted. 
The animal had appeared ill, it was fever- 
ish, and emaciating rapidly. The rabbit 
1 ived considerably longer — three months ; 
after death, tubercles were found in the 
liver and lung. From these experiments 
it was evident that although no tubercular 
lesions could be found in the organs of the 
child, yet the latter were capable of in- 
fecting animals ; and had the child survived, 
it would have undoubtedly developed tu- 
berculosis at an early age. It is a point of 
great interest to read that tubercle bacilli 
were found in the umbilical cord and in 
the blood of the umbilical vein. — Lancet. 



MEDICAL CHEMISTRY. 



A NEW DEPARTURE IN FILTERING 
APPARATUS 

E. Martin has recently devised the 
following improvement in filtering appara- 
tus. An endless traveling band, made of 
any material suitable for filtering purposes, 
is so arranged as to assume for a portion of 
its length the form of an open horizontal 
trough or cistern. For this purpose the 
band is mounted in a manner to cause it 
to make a slight descent at one end, and 
and simultaneously to have the two sides 
or edges of the fabric turned up. In this 
form the band extends horizontally for a 
certain length, and is then made to rise 
again on an incline and to spread out flat. 



40 



News and Miscellany. 



Vol. lxvii 



In this manner a shallow traveling cis- 
tern is formed between the two inclines 
wherein the water for filtering is received. 

The speed of the traveling band may be 
regulated in such a way as to allow it to 
be coated to any desired degree with the 
matter arrested from the filtered liquid, 
and on continuing to travel it may be con- 
ducted through cleansing apparatus, 
whence it will return cleaned and ready 
for the renewal of the operation. 



REACTION OF SALOL. 

According to Journal de Pharmacie d 
Anvers, the following is a characteristic of 
salol. A small quantity of salol is added 
to a few drops of nitro sulphuric acid. 
The mixture is colored yellow and on stir- 
ring with a glass rod it changes to brown 
and then to green. On diluting with 
about 50 gm. of water the liquid assumes 
a rose color, the green color reappearing 
on adding ammonia. Resorcin treated in 
the same manner gives a deep blue color ; 
on dilution, red. In the latter solution, 
ammonia causes the blue color to reappear. 



DELICATE TEST FOR ALUM IN DRINK- 
ING WATER. 

E. H. Richards contributes to Tech- 
nology Quarterly the following, which it 
is said, will detect 1 part of alum in 1,000, 
000 parts of water ( 1 grain in about 17 
gallons) : To 25 ccm. of water (concen- 
trated from 1 litre or more if necessary,) 
are added a few drops of freshly-prepared 
logwood decoction; any alkali is neutral- 
ized and the color brightened by the addi- 
tion of two or three drops of acetic acid. 
By comparison with standard solutions 
the amount of alum present may be deter- 
mined. The logwood chips must be treated 
with boiling water two or three times 
before finally extracting for the color, as 
the first extraction gives a yellow color, 
the third or fourth a deep red. 



A NEW SOLVENT OF CAMPHOR. 

From the frequency with which the in- 
dications for the subcutaneous injections 
are met with it is evident that a good and 
reliable solvent for this substance is a great 
desideratum. 



Ethereal solutions rapidly evaporate. 
Alcoholic solutions also evaporate and the 
camphor becomes precipitated, so that in- 
jections of such solutions produce severe 
pain or even abscess. Solutions' of cam- 
phor in oil are difficult to employ, besides 
possessing the disadvantage of the liability 
of becoming rancid. 

In the Zeitschrift fur Therapie for 
September 1st, 1891, Dr. Karl Rosner 
recommends in the highest terms a solu- 
tion of camphor in liquid paraffin, which, 
when slightly warmed, forms a .perfectly 
clear and limpid solution. He states that 
he has kept this solution for more than 
five years without its properties becoming 
changed. 



NEWS AND MISCELLANY. 



INTERNATIONAL DERMATOLOGICAL 
CONGRESS IN VIENNA. 

The second meeting of the International 
Dermatological Congress will be held in 
Vienna from the 5th to the 10th of Sep- 
tember 1892. 

Many of the most distinguished repre- 
sentatives of dermatology and Syphilo- 
graphy from all countries have promised 
to present papers and the indications are 
that the meeting will be a great success 
from a scientific standpoint. 

The committee on organization, through 
the President, Prof. Kapesi, has extended 
a cordial invitation to the members of the 
American Dermatological Association and 
of the New York Dermatological Society 
and others interested in Dermatology in 
this country to be present. 

The membership fee (five dollars) should 
be sent with titles of papers intended for 
presentation to the Secretary for North 
America, Dr. Prince A. Morrow, 66 West 
40th street, New York, or to the Secretary 
General of the Congress, Dr. Gustav 
Riehl, Wien is, Bellaria Strasse 12. 



A successful case of bone-grafting is re- 
ported from Allahabad, a solution of con- 
tinuity in the anterior layer of the frontal 
sinus having been induced to take on 
osseous repair by sprinkling the surface 
with u small fragments " of the hip-bone 
of a newly killed dog. — Med. Press. 



Whole No. 1845. 



10 Cents a Copy 



A Weekly Journal. 



Established in 1853 by S. W. BUTIyER, M. D, 



THE 

MEDICAL AND SURGICAL 
REPORTER 



EDWARD T, R El CHERT, M. D., 

Entered as Second-Class matter at Philadelphia P. O. 



Editor, V 

P. O. BOX 843, PHII,A., PA/<^ft 




CLINICAL LECTURES. 

Robert Olshacsex, M. D., Berlin, Germany. 
Eclampsia 



A. M. Phelps, M. D., New York. N. Y. 
The Operative Treatment of Club-foot ; the Diag- 
nosis and Treatment of Hip-joint Disease 

COMMUNICATIONS . 

Mark A. Eodgers, M. D., Allegheny, Pa. 
Report of a few Laparotomies done in the Alle- 
gheny General Hospital by R. Stansbury Sutton, 
M. D 

A. Eichler, M. D., San Francisco, Cal. 
Aristol and Europhen 



j SOCIETY REPORTS. 

Stated Meeting of the Medico- Chirurgical Society 
of Louisville 



JohnB. Craxdael, M. D., Sterling, 111. 
A Case of an Old Right Inguinal Hernia, Irredu- 
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E. W. Kellogg-, M. D., Milwaukee, Wis. 
Oleum Terebinthina? as a Remedy for Croup, 
with a Report of Fifteen Cases ; Discussion 



SELECTED FORMULAE 

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Ether Versus Chloroform as an Anaesthetic. 

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Pediatrics 

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THE 



MEDICAL AND SURGICAL 
REPORTER. 



No. 1845. 



PHILADELPHIA, JULY 9, 1892. 



Vol. LXVII— No 2. 



Clinical Xectures, 



ECLAMPSIA. 



By DE. EOBERT OLSHAUSEN, 

BERLIN, GERMANY. 



PART II. 

{Continued from page 5.) 

THE PATHOLOGICAL ANATOMY OF 
ECLAMPSIA. 

Gentlemen: — If we now proceed to a con- 
sideration of the pathological anatomy of 
eclampsia, I mnst first state that changes 
in the kidneys are found in all fatal cases. 

In twenty-two cases of thirty-seven, I 
found in the kidney evidences of acute or 
subacute processes, which principally af- 
fected the parenchyma of the kidney, and 
then would either cause an acute fatty de- 
generation of the epithelium of the kidney 
substance (so-called "kidney of preg- 
nancy") yet seldom affecting the glom-' 
eruli or else it would reveal itself in a 
severe change of the parenchyma. In two 
of these cases the pathological changes 
were only of a slight degree. In other 
cases there existed simultaneously a chronic 
interstitial nephritis, to which the acute 
changes of the parenchyma had been 
added. Five such cases were found. Four 
were found in which there was only the 
interstitial nephritis. In one case there 
was a chronic interstitial nephritis on the 
left side, and a recent parenchymatous 
nephritis on the right side. Usually the 
parenchymatous changes affected both kid- 
neys. In the majority of cases of simple 
or complicated parenchymatous changes 
there were numerous apoplexies of the 
parenchyma; this also occurred in one 
case of glomerulo-nephritis. 

In two other cases there was only a 



hyperemia of the kidneys, although to be 
sure the patient did not die until the 
twenty-ninth post-partum day, and then 
with pneumo-thorax. In this case, the 
renal symptoms had doubtlessly receded. 

In one case only were we unable to dis- 
cover any pathological change in the kid- 
ney. The patient had had twenty-one 
eclamptic attacks, half of which occurred 
post-partum, and died on the fifth day 
after delivery, from pneumonia. Perhaps 
in this case also the pathological condi- 
tions of the kidneys had receded, for dur- 
ing the eclamptic attacks her urine con- 
tained large quantities of albumin of 
its volume) as well as many hyaline and 
granulated cylinders, renal epithelium and 
red blood-corpuscles. 

In the last of the thirty-seven cases both 
kidneys were found diseased in an extra- 
ordinary way, and this case is of special 
importance in reference to the meaning of 
eclampsia, and of special general interest. 
The right kidney was a so-called ' ' foetal 
cystic kidney," only about the size of a pig- 
eon's egg. The right ureter was of un- 
usual smallness, and thread-like. The left 
kidney was hydroscopic in a high degree, 
so that it only consisted of a single pyra- 
mid. The left ureter, from the entrance 
of the pelvis up, was enlarged to the size 
of one's little finger. We shall return to 
a consideration further on. 

I add to this description of the patho- 
logical anatomy of the kidneys that of the 
ureters. In the thirty- seven cases in which 
I performed autopsies, the right ureter 
was found dilated in five instances, but 
only moderately and without, or at least 
very slight, hydronephrosis. In one case 
I found slight right- sided hydronephrosis 
without dilatation of the ureter. In a 
seventh case, finally, there was a left-sided 
hydronephrosis with dilatation of the ure- 
. ter, and at the same time a right-sided 
cystic-kidney. 



44 



Clinical Lectures. 



Vol. lxvii 



More, even, than the frequency of the 
attacks, must their character or nature be 
taken into consideration. In such cases 
of eclampsia in which the disease appears 
at the end of birth, or more frequently 
even during the first hour after the birth, 
and then ceases after one or two convul 
sions — in such cases the convulsions are 
usually of a light nature. 

On the contrary, there rarely occur 
cas.es of eclampsia, of the most unfavorable 
prognosis, which occur sometimes intra- 
partum and sometimes post-partum, in 
the intensity of the convulsion is the most 
important feature. In these, the attacks 
occur, as a rule, in quick succession, and 
nothing but the most energetic use of mor- 
phine will influence them in any way 
whatever. 

Any great increase of temperature must 
be regarded as a most unfavorable symp- 
tom. In thirty-seven cases there was a 
rise of temperature of 39° C. or over, 
either during the attacks or in the coma 
that followed; of these thirty- seven cases, 
fifteen died, or 40.5 percent. In twenty- 
seven cases in which the temperature did 
not exceed 39.9° C, there were nine 
deaths, or 33J- per cent. 

The rise of temperature depends greatly 
upon the number of convulsions. This 
may be seen by the following: In thirty- 
one cases in which the temperature reached 
39° C. or over, the average number of 
convulsions was fifteen, while on the con- 
trary in one hundred cases in which the 
temperature did not reach 39° C, the 
average number of attacks was only nine. 

Of still greater importance than the 
temperature, is the pulse. When the 
pulse increases in poorness, that is in small- 
ness and frequency, whether during the 
convulsions or after they have ceased, it is 
always a bad symptom. 

In the majority of cases the prognosis 
remains very doubtful, not only during 
the continuance of the convulsions, but 
also during the coma. Subsequent dis- 
eases must also be taken into considera- 
tion, among these may be mentioned lung 
troubles (pneumonia) and septicaemia, as 
playing the most important r61e. From 
the first cause three of our patients died, 
and from the last, four. 

The frequency of sepsis in eclampsia 
may be seen from all statistics of the dis- 
ease. Lohlein, out of one hundred and 
six cases of eclampsia, reports forty deaths 



and four cases of sepsis; Brummerstadt 
out of 135 cases of eclampsia reports fifty- 
one deaths and thirteen cases of puerperal 
infection. C. Braun, out of forty-four 
cases, reports nine of puerperal infection, 
five of which ended fatally; Schauta out 
of 90 deaths from eclampsia, reports that 
twenty- seven were from peurperal infect- 
ion. In Lohlein's latest statistics, there 
were to be seen only four cases of sepsis 
and pyaemia in three hundred and twenty- 
five cases of eclampsia. Yet it is very 
possible that in the thirty different reports 
from which these statistics are compiled, 
this point may not have received special 
consideration in some of them. The 
frequency of septic infection may be ex- 
plained by the frequency of operative in- 
terference, but may also be connected with 
a certain predisposition to septic infection, 
on the part of eclamptic subjects, similarly 
as acutely anaemic subjects are liable to 
septic infection. 

The prognosis for the child is even 
worse than for the mother. 

When we look aside from cases of pure 
puerperal eclampsia, and also from such 
cases of eclampsia occurring in pregnancy 
in which • the disease did not terminate 
the pregnancy (5 cases), further also from 
such cases in which the death of the 
mother occurred, ante-partum (9 cases), 
and finally from those cases in which at 
the time of the interruption of pregnancy 
by the disease, the foetus was not yet 
viable, there remain still (153) children, 
of which forty-three were brought into 
the world dead ; giving thus a mortality 
of 28 per cent. 

The number of convulsions and the 
frequency of their recurrence affects the 
life of the child even more seriously than 
that of the mother. After twelve or 
thirteen attacks the child usually dies, 
and often even long before this. Yet we 
have thirteen cases to report in which the 
children were born alive, although they 
had endured fifteen convulsions while yet 
in the mother. But the majority of the 
children who had lived through so many 
maternal convulsions, died the next day. 

The narcotics which we are frequently 
compelled to make such free use of, are 
also undoubtedly deleterious to the child's 
life. After the use of full doses of mor- 
phine we have frequently seen the children 
born to the world deeply narcotised by the 
drug. Even when all signs of asphyxia 



July 9, 1892. Clinical Lectures. 45 



were absent, the respirations of the child 
were always shallow and slow, and its 
movements were few and torpid. Oc- 
casionally the pupil was fixed and con- 
tracted. Some of these children, although 
breathing regularly, could not be made to 
cry, by any exciting means. 

A superficial examination of such child- 
ren would lead one to believe that they 
were asphyxiated, but a closer view will 
soon reveal the true state of affairs. 

THE THERAPY OF ECLAMPSIA. 

The therapy of eclampsia has heretofore 
been one of pure empiricism. In distinc- 
tion to the largely used treatment by chlo- 
roform anaesthesia, which has been so ex- 
tensively employed, as it was also at this 
clinic, I prefer the use of morphine in 
large doses, as suggested by G. Veit. As 
an initial I give 0.03 gramme, hypoder- 
mically, and if the convulsions do not 
cease soon follow it by additional doses. 
In the course of treatment we seldom give 
over 0.06 gramme, or indeed altogether, 
although in cases that progressed chroni- 
cally we have, during the course of sev- 
eral days given much more; in one 
case giving as much as 0.27 gramme 
in four days, with good results to the 
mother. 

When the condition of the pupils or of 
the pulse would indicate that the further 
exhibition of the drug is not advisable, 
and in case the attacks still continue, 
I substitute chloral, by rectal injection, 
in 2.0 or 3.0 gramme doses. 

The use of chloform seems eminently 
suited in those comparatively rare cases, 
where the attacks return after pretty reg- 
ular intervals. In all other cases one must 
either prolong the* anaesthesia for a very 
long time — which to us does not seem ad- 
visable — or else administer an anaesthetic 
at the first intimation of the approach of 
an attack ; in this latter case, however, the 
remedy always comes too late to abort the 
attack. 

During the continuance of the eclamp- 
sia, we make no use of either diaphoretics, 
bromides, wet-packs, or baths. Indeed we 
shun all unnecessary handling of the 
patient, because this only too frequently 
will excite an attack. There have been 
cases in which a careful digital examina- 
tion of the uterus, the expression of the 
placenta, a change of the patient's bedding, 
and even the puncture of the hypodermic 



needle have been sufficient to excite a con- 
vulsion. 

When in deep coma, the rattling in the 
upper air passages becomes continued, as- 
phyxia is imminent. This can be pre- 
vented by bending the patient forward 
over the side of the bed, so that the head 
is greatly lowered. In this way very large 
quantities of mucous will be discharged 
from the mouth, the respiration will be- 
come free and the cyanosis will disappear. 
The mucous may also be removed with 
small brushes of cotton or small sponges, 
which are inserted into the flames, one 
after the other, by the dozen. In this way 
the same results are obtained. In many 
cases I feel convinced that we have saved 
our patients from an immediate death from 
asphyxia by these means. I also claim the 
great importance of the watchful care of 
a physician at the bedside of the patient, 
so as to be always ready in case of any such 
emergency. In Lohlein's recent publica- 
tion on the subject we may read that 
Schatz recommended the frequent sinking 
of the head of eclampsties, but apparently 
not for the same reason. 

Eegarding operative interferences, v. 
HerfPs* recently recommended practice of 
rupturing the amniotic sac in order to 
accelerate the birth, is at all events worth 
the trial, and in multipara? may be 
regarded as a pretty certain means of 
accomplishing this end. The frequent 
use of the forceps in cases of well dilated 
cervix with a deep position of the head, is 
equally recommended on all sides. Ver- 
sion, for instance, in cases of a contracted 
cervix, and extraction with the aid of free 
incisions, does not seem to me to be recom- 
mendable. On the contrary, I consider 
Caesarean section as practiced by Hal- 
bertsma and Kaltenbach — the requirements 
of v. Herff being fulfilled — as a both justi- 
fiable and valuable procedure. The 
requirements of v. Herff are to the effect 
that if the child is still alive in a severe 
case of eclampsia, and a natural birth is 
impossible, or the dilatation of the cervix 
is delayed, then this operation is justifia- 
ble. . Now, when the mortality of the 
operation has been so greatly reduced, a 
successful result is very possible. 

In how far the use of the forceps and 
version affect the mortality, I should like 
to elucidate by giving the following data: 
Out of sixty-four forcep deliveries, ten 

*v. Herff, Berliner Klinik, HeftT 32^ 189L 



46 



Clinical Lectures. 



Vol. lxvii 



died ; while in nine cases of version , five 
resulted fatally. 

If we look aside from the ten deaths 
occurring ante-partum, the mortality table 
might be arranged as follows : 

In 111 spontaneous births, there were 24 
deaths, or a death rate of 21.6 per cent. ; 
while in 77 of instrumental deliveries, 
there were 16 deaths, or a death rate of 
20.8 per cent. 

Among the last were included at least 
three cases of sepsis. If those cases in 
which version was used were to have been 
excluded from the statistics, the death 
rates in favor of the operative births would 
have been still more favorable. 

That the termination of delivery benefi- 
cially affects the disease — since in a large 
number of cases the attacks then quickly 
cease — is denied by both Brummerstadt 
and Schauta. But all the same the clini- 
cal facts undoubtedly point to the benefi- 
cial influence of a speedy termination of 
the birth. If I search through my own 
cases and see what sort of an answer they 
would return to such a question, I find 
the following: 

In seventy-three cases of spontaneous 
births, no attacks occurred after delivery 
in forty-three cases, and three or over in 
thirteen patients. 

In seventy cases of operatively ended 
pregnancy, no attacks occurred after 
delivery in forty-nine cases; one. or two 
attacks in twelve cases, and three or more 
attacks in nine cases. 

In 143 cases, the eclampsia ceased with 
the completion of delivery in ninety-two 
cases. It returned once or twice in twen- 
ty-nine cases, and more than three times 
in twenty-two instances. 

In about 85 per cent, of cases the 
eclampsia ceases with delivery, or else soon 
after. 

(To be continued.) 



CHOREA. 

Out of a total of 18,074 children treated 
in five years at the polyclinic of the Charite 
in Berlin, Meyer found 121 instances of 
chorea, or a proportion of 6.6 percent.; 
11 of these cases (nine per cent.) were at 
the same time rheumatic ; '3 had, along with 
their rheumatism and chorea, an organic 
affection of the heart; 13 (ten per cent.) 
had chorea and heart disease without the 
rheumatism. — Berliner klin. Wochens. 



THE OPERATIVE TREATMENT OF 
CLUB-FOOT; THE DIAGNOSIS 
AND TREATMENT OF HIP- 
JOINT DISEASE. 



By A. M. PHELPS, M. D., 

PROFESSOR OF ORTHOPEDIC SURGERY, ST. Y. 
POST GRADUATE MEDICAL SCHOOL AND 
HOSPITAL, NEW YORK CITY. 



Gentlemen : — I shall first operate upon 
this case of double congenital club foot. 
This little baby 7 months old, has a talipes 
equino-varus of the left foot, and a varus 
of the right. Instead of treating it for 
many months by instruments, I propose to 
divide at once the contracted parts, placing 
the foot in a super-corrected position, and 
dressing it with plaster of Paris. We can 
accomplish more in a few moments in this 
way, with equally good result than can be 
done by three or four months of careful 
treatment with the best machines that have 
ever been devised. Always remember in 
operating for club-foot : First, to manip- 
ulate the foot thoroughly in order to over- 
come the contracted parts ; this will put the 
contrsictured parts on the stretch ; secondly, 
perform subcutaneous tenotomy on the 
parts which first offer resistance, and in 
the order in which they became contracted, 
beginning with the tendo Achillis. Hav- 
ing severed this tendon, pull the foot as 
nearly as possible into position ; then cut 
another resisting portion, then manipulate 
the parts again before cutting any further, 
and if you find that the skin, is short and re- 
sisting, make an open incision, beginning 
just in front of the inner malleolus, and 
extending one-third the distance across the 
foot, putting the deep parts on the stretch 
by manipulation and then cutting them if 
necessary. If this fails to relieve the de- 
formity, do a linear osteotomy through 
the neck of the astragalus ; if this fails, re- 
move a V-shaped piece from the astraga- 
lus ; failing in this, remove the cuboid and 
scaphoid ; and if you are still unsuccessful, 
perform Pirogoff's amputation. Of course, 
I am talking to you about extreme cases 
when alluding to amputative extensive os- 
teotomy. 

Having now divided the tendo Achillis 
in the right foot of our little patient, I 
shall endeavor to put the foot in a super- 
corrected position of calcaneus. As this 
cannot be done, I again introduce my ten- 
otome through the same incision, and di- 



July 9, 1892. 



Clinical Lectures. 



47 



vide any contracted bands that may be 
present. The abductor pollicis and the 
plantar fascia are next divided, and after 
further manipulation, I find that the long 
flexor of the great toe is short, so this is 
divided, and I am now able to super-cor- 
rect both the varus and the equinus. To 
stop short of this, would be a great mis- 
take. The foot is now dressed with Lis- 
ter's " protective," and gauze, i( bunch- 
ing " it up over the wound on the plantar 
surface so as to make a little more pressure 
at this point, and so control the oozing of 
blood from the divided muscular branches, 
A gauze bandage, and a plaster of Paris 
dressing complete the dressing. It is only 
necessary to cut the plantar fascia in the 
left foot, and apply the same dressing. 
Only do open operation when subcutaneous 
ones are not safe nor efficient. 

I shall next invite your attention to the 
general principles underlying the diagno- 
sis and treatment of hip joint disease, 
and I shall begin by showing you this little 
girl with double congenital dislocation of 
the hip as I shall again allude to it when 
speaking of differential diagnosis. This 
child is wearing a machine which I de- 
vised, and which consists of a band around 
the hips, and two perineal straps, with 
adjustable and even pads so arranged that 
greater or less pressure may be made over 
the great trochanters, thus pressing them 
firmly against the ilium, and overcoming 
the tendency of the head of the bone to 
slip up on to the dorsum. 

Our next patient is a little girl with true 
inflammatory disease of the hip joint. The 
joint is extremely sensitive, and is filled 
with fluid. Now, what are the general 
symptoms of joint disease ? They are, pain, 
heat, swelling, pain on joint pressure, 
limited motion, spasm of muscles, atrophy, 
and deformity. What are the symptoms 
of hip- joint disease ? All of these eight, 
and a few others. Patients with hip- 
joint disease have pain in the fcnee, flatten- 
ing of the buttocks, obliteration of the 
gluteal fold, flexion of the limb, and in 
the first and second stages, abduction and 
apparent lengthening. If there be true 
disease of the bone, there is also atrophy 
of the limb ; Barwell of England first called 
attention to this fact. In the case before 
us, there is no difficulty in determining an 
increase of local temperature, the presence 
of swelling, and the limitation of motion. 
To ascertain whether or not there is abduc- 



tion, place the patient on the back in such 
a position that a line drawn between the 
anterior superior spines of the ilium will 
be parallel to another line drawn across 
the body at a higher level, and then notic- 
ing the position of the limbs with reference 
to the median line. In testing for flexion, 
we place the limb so that the popliteal 
space touches the table, when we find that 
the buttock arches very slightly, showing 
that there is still in this patient a little 
flexion. Thomas's method is also a good 
one. This deformity is due to spasm of 
the iliacus and ' psoas muscles. There is 
also some atrophy of this child's limb. 
The symptoms, then, would lead you to 
believe that this child had joint disease, 
but we would have nearly all these symp- 
toms with sacro-iliac disease, or with dis- 
ease located in the acetabulum external to 
the joint. If with your hands pressing 
firmly both iliac crests towards the median 
line, pain is not elicited we may know that 
there is no sacro-iliac disease. If the dis- 
ease was located external to the acetabulum, 
or was extracapsular, you would have all 
the symptoms present in this case, except 
pain on joint pressure. But we have not 
yet differentiated between disease of the 
bone and of the soft parts. I know that 
there is disease of the bone here, because 
of the rapid atrophy of the soft parts. 
When the terminal plates of the nerves 
within the area of disease are pressed upon, 
the muscles supplying the diseased joint are, 
by reflex action, thrown into spasm; but 
when the soft parts are diseased, on ac- 
count of their elasticity, but little pressure 
is made upon the nerve plates, and hence 
there is slight muscular spasm, slight de- 
formity and slight atrophy. 

Let us now differentiate between a true 
inflammatory disease of the joint, which has 
resulted in destruction of that joint, with 
possibly a dislocation and a case of conge- 
nital dislocation of the hip, or one of intra- 
capsular fracture, or a diastasis of the 
head. If the great trochanter be above 
Nelaton's line, namely, a line drawn from 
the anterior superior spinous process of 
the ilium to the tuberosity of the ischium, 
you may know that there is a dislocation, 
a diastasis, an extracapsular fracture, or 
hip-joint disease. This child's great tro- 
chanter does not project above Nelaton ? s 
line. Many cases of hip- joint disease 
come to you after dislocation has taken 
place, and you will find from two to four 



48 



Clinical Lectures. 



Vol. lxvii 



inches of shortening. How shall you dis- 
tinguish between them and a case of con- 
genital dislocation of the hip? Let us 
look again for a moment at the first case, 
the little girl with congenital dislocation 
of the hip. You would look for limited 
motion in every direction in case of hip- 
joint disease, but on examining this case, 
I find nearly perfect motion, no history of 
inflammatory action, and I can both feel 
and see the head of the bone as it rotates. 
If the dislocation were due to inflamma- 
tory disease, we would expect to find the 
head of the bone held up against the 
Hum, and probably not smooth, but more 
or less distorted. Is this a case of diasta- 
sis, or a true case of dislocation? I know 
it is not a diastasis, because I can feel the 
head of the bone, and because when I 
rotate the limb, the trochanter rotates 
in a circle, which it would not do if there 
were a diastasis. The mother says there 
has been no injury, hence, the condition 
must have occurred at birth, or in utero. 
No method of treatment with which I am 
familiar will effect any great improvement 
in the condition of such a case of double 
congenital dislocation of the hip short of 
an operation, and the contrivance for mak- 
ing pressure on the trochanters seems to 
me to be as useful as any yet devised. If 
there be a difference in the length of the 
limbs, of course, this should equalized by 
a high shoe. 

Now, in regard to the treatment of hip- 
joint disease, let me, in the first place, 
impress upon you that it is a surgical law 
which no general or orthopedic surgeon 
should violate, that when a part is 
inflamed, that part should be put at rest 
until it is cured, no matter how long a 
time may be required to effect this. 
Another important rule is, overcome the 
spasm of the muscles operating upon 
the joint, as this spasm produces great 
■intra- articular pressure, and will cer- 
tainly result in the destruction of the joint 
if not controlled by traction exerted 
against the contracted muscles . To do this, 
you must make not only longitudinal trac- 
tion in the line of the deformity, but also 
lateral traction in the axU of the neck to 
overcome the spasm of the adductors and 
the abductors. Another important point 
is, when will you begin passive motion® 
Never. I care not how long you keep the 
joint immobilized, it will not be anchylosed, 
because of the rest you give it; but if 



anchylosis does occur, it will be on account 
of the duration, severity and extent of the 
inflammation, and the subsequent cicatri- 
cial contraction, and no amount of pas- 
sive motion will prevent this after this 
cicatricial contraction has once begun. 
Therefore, I say, put all patients with 
sensitive joints to bed, and also those 
having deformity, because you can over- 
come the deformity more quickly with 
them in bed. After the deformity has 
been reduced, and all tenderness has 
disappeared, put the patient on a lateral 
traction fixation splint. Never allow them 
to walk upon the splint until cured, for 
the constant trauma produced by walking 
ivill prolong the disease, and more than 
fifty per cent, of such cases so treated have 
anchylosis, and hardly a single case will 
recover loithout deformity; hencej you 
must use a high shoe on the well leg, and 
not allow the splint to touch the ground. 
These are the principles of treatment, and 
if faithfully carried out, I think they will 
enable you to obtain far better results 
than have hitherto been observed in 
hip- joint disease. We seldom see anchy- 
losis and our cases are treated as I have 
suggested. All recovered without angu- 
lar deformity. 

Another important question which will 
confront you is, when shall you operate 
upon an abscess? 1 answer, just as soon 
as you are sure pus is present, except when 
the abscess causes no disturbance, there is 
no tendency to burrowing , and occasionally 
also where the abscess is so located, that if 
opened, the ring of the brace tuould press 
upon the ivound. "An empty house is 
better than a bad tenant," and I have never 
regretted opening an abscess. Having in- 
cised an abscess, you can then introduce 
your finger , and ascertain positively the 
exact condition present. You may find 
the head of the bone separated from the 
shaft, or you may Und positive indications 
for an incision, at any rate, by opening 
an abscess, you are made master of the 
situation. 

In connection with the subject of im- 
mobilization and anchylosis, I would like 
to show you this man, who is said to have 
had inflammatory rheumatism, and whose 
entire spine is a?ichylosed; yet, his spine 
has been constantly moved and subjected to 
all kinds of massage — the very plan which 
is supposed to prevent anchylosis, but an- 
chylosis has resulted. Are you going to 



July 9, 1892. 



Clinical Lectures. 



49 



bow doivn humbly to established precedent, 
or are you going to accept these facts, and 
shape your treatment accordingly? Con- 
trast this with the next patient, a man 
who had an effusion in the left knee joint, 
nine months ago, and whose limb was put 
up in plaster of Paris, first for five 
months, and subsequently again for four 
months. The splint has been removed to- 
day, and you see that there is no anchylo- 
sis in this knee joint notwithstanding such 
prolonged immobilization. If you consult 
Dr. Sayre's book on Orthopedic Surgery, 
you will find a case of hip-joint disease 
reported, in which a child was kept in a 
wire cuirass for a few months, and the 
child not only came out with anchylosis 
of the opposite hip, but of the joints of 
the opposite extremity, and of the entire 
spine, and this was attributed to the im- 
mobilization ; yet strange to say, the side 
in which the disease existed, recovered 
without anchylosis. A mistake in diagno- 
sis was certainly made. By all means do 
not employ passive motion, but active 
motion, after the patient is cured ; let the 
patient loosen up the joint, his feelings 
will regulate the degree of motion. Pass- 
ive motion will probably excite a fresh in- 
flammation, which will probably result in 
anchylosis. 

The last patient I shall show you is a 
physician, forty-one years of age, who had 
an extremely severe form of talipes equino- 
valgus. I could not straighten the left 
foot, you. will remember, after the open in- 
cision, or by manual force, but with the 
aid of a powerful club-foot machine, I suc- 
ceeded in pulling the heel down, and I 
think the result will be very satisfactory. 
You will remember that we divided the 
nerve ; it is always better to cut a nerve 
than leave it upon the stretch, for sensa- 
tion will invariably return. In this 
patient, it is already beginning to 
return. 

Without the machine, some form of os- 
teotomy would have been necessary, but as 
there is a mortality of from three to five 
per cent, from osteotomy, it should be 
avoided whenever possible. If you follow 
the rules already laid down, you will prob- 
ably be able to avoid it in about ninety per 
cent, of all your cases. The open incision 
has its legitimate place in surgery, between 
subcutaneous tenotomy and osteotomy. 
This patient was my two hundredth case, 
and I have never heard of a single death 



from this open incision . method. — P.S. 
Three months later the patient was dis- 
charged with perfect feet. 

THE INFLUENZA WAVE IN EGYPT. 

The influenza wave which attacked 
Egypt on the Mediterranean border of the 
Delta, after gradually spreading south- 
ward, has now reached the Soudan, into 
which it is apparently disappearing. The 
influence of the disease on the mortuary 
returns was first apparent in Lower Egypt 
in the week ending January 14th last, 
when the death-rate went up from an av- 
erage of 41.9 for the preceding six years, 
to 52.8 per 1,000 in nineteen of the prin- 
cipal towns. The high rate steadily in- 
creased up to February 4th, when the rate 
was given as 71.9, against the average of 
42.8. The following week it began to 
diminish, but it was not until the week 
ending March 24th that the normal rate 
of mortality was again reached. During 
these eleven weeks the deaths of 358 na- 
tives and 24 Europeans were reported as 
directly due to influenza. In the eleven 
towns of Upper Egypt, from which returns 
are furnished, the most southern being 
Esneh, the death-rate did not show any 
increase till the week ending February 18th, 
when it rose to 46.9, the average being 
37.1. The highest rate reached was dur- 
ing the week ending March 10th, when 
55.6 per 1,000 was recorded; but at the 
date of the last return, that is, March 31st, 
it was above the average, being 49.8. In 
these eleven towns the number of deaths 
ascribed directly to influenza during the 
period was 45. The military report from 
Assouan show that between February 14th 
and 27th 44 cases of influenza were treated 
among the soldiers, while at Wady Haifa 
the number was 132, with one death. 
From the latter date to March 19th, 3 fa- 
tal cases occured at Assouan, and 173 at 
Wady Haifa ; and at the latter station there 
were 5 deaths. There were only 4 cases 
left under treatment, so the epidemic may 
be looked on as almost extinguished as far 
as the military are concerned. In the week 
ending April 7th the mortality in t T pper 
Egypt fell to 43. 9 per 1,000, although there 
were 5 deaths said to be due to influenza. 
At Wady Haifa, on April 9th, there was a 
clean bill of health from the military hospi- 
tal as far as the epidemic was concerned, 
but since the date of the last report there 
had been 3 deaths. — Brit. Med. Jour. 



50 



Communications. 



Vol. lxvii 



Communications. 



REPORT OF A FEW LAPAROTOMIES 
DONE IN THE ALLEGHENY 
GENERAL HOSPITAL. BY 
R. STANSBURY SUT- 
TON, M. D., GYNAE- 
COLOGIST TO 
THE HOSPI- 
TAL. 



By MARK A. RODGERS, M. D. 

Before submitting the reports of these 
cases, I shall attempt to describe the oper- 
ator's technique. 

The method employed by Dr. Sutton for 
the disinfection of the skin, is that which 
has been described at various times by Mc 
Lean and Welsh of the Johns Hopkins 
University, with slight modifications. 
Without pointing out these modifications 
I shall describe the method as used by Dr. 
Sutton : 

1. The forearms and hands of the oper- 
ator and his assistants are vigorously 
scrubbed with a coarse sterilized nail-brush, 
warm water and soap, for several minutes: 
nails pared and cleaned. 

2. The hands are then placed in a strong- 
solution of potassium permanganate for 
one or two minutes, after which the excess 
of this solution is washed off with distilled 
water. 

3. They are then placed in a freshly 
prepared solution of hyposulphurous acid 
until decolorization is effected. 

4. They are then immersed in distilled 
water. 

The hyposulphurous acid solution is pre- 
pared by mixing just before using, concen- 
trated solutions of oxalic acid and hypo- 
sulphite of soda; the result being the 
formation of sodium oxalate and the liber- 
ation of the acid, which has great decolor- 
izing power, and quickly removes the 
stain of the permanganate. 

The remarkable point to be observed in 
this process of disinfection is the absence 
of corrosive sublimate. The results as will 
appear from the following report appar- 
ently justify its omission. 

As an additional precaution, the sur- 
geon, his assistant, the nurses and all who 
are in any way engaged in the operation, 
receive prior to entering the operating 
room, a bath, after which they are dressed 
in sterilized wash clothing. 



The abdomen having been prepared with 
all attention to the details of modern 
asepsis, the patient is placed after an aesthe- 
tization on an Edebold table. The abdo- 
men is opened by three incisions, as fol- 
lows: The first exposes the linia alba; the 
second the peritoneum, and the third after 
the arrest of haemorrhage, opens the ab- 
dominal cavity. The time occupied by 
this part of the operation is usually from 
ten to fifteen seconds. The incisions are 
made by a long continuous sweep of the 
knife, and the length of the incision has 
therefore not much effect upon the time 
required. The cavity opened, the opera- 
tion proceeds, of course, as required by the 
existing condition. The general points 
being, that flushing, sponging and drain- 
age are to as great an extent as possible 
evaded; that chemicals are never used 
within the peritoneal sack under any cir- 
cumstances. Haemorrhage is controlled by 
the usual methods — torsion, suture, liga- 
ture, sponge packing, hot douche or in 
extreme cases, styptics. Occasionally des- 
pite these measures persistent oozing has 
to be dealt with, and under such circum- 
stances drainage is reluctantly resorted to, 
combined with extra-abdominal compres- 
sion after closure of the wound. 

Silk, which is completely soluble in a 
concentrated solution of potassium hy- 
droxide, is the material used for ligature. 
The abdominal wound is also closed with 
silk, with if necessary superficial sutures 
of silk or cat-gut. 

The dressings are extremely simple, con- 
sisting of eight layers of sterilized gauze, 
which after removal from a solution of 
1 :500 bichloride of mercury, have been 
rung out in three changes of distilled 
water. On this is placed a layer of aseptic 
cotton and the whole held in place by a 
many-tailed binder. This dressing is not 
molested under ordinary circumstances un- 
til the seventh day, at which time every 
alternate stitch is removed ; on the eighth 
day the remaining sutures are withdrawn. 
At this time union has usually taken place 
throughout by first intention. A single 
layer of gauze is now applied and held in 
place by adhesive strips, which also serve 
to support the wound. This is only 
changed for the remaining few days as 
cleanliness or the patient's comfort dictate. 
On the fourteenth day the patient is usu- 
ally allowed to sit up, and a few days later 
leaves the hospital. 



July 9, 1892. 



Communications. 



51 



The operating room is a model. 
Through the liberality of Mr. D. E. Park, 
a member of the board of directors of the 
hospital, an operating room has just been 
completed for the Gynaecological depart- 
ment, which is probably, both from an 
esthetic and practical point of view second 
to none in this country. It is situated on 
the third floor of the building and is ac- 
cessible from all floors by a hydraulic eleva- 
tor, large enough to carry comfortably a 
bed or operating table and attendents. 
The room has a southern and eastern ex- 
posure, the high elevation besides giving a 
good quality of air and making ventilation 
consequently perfect, gives excellent op- 
portunities for lighting, which in the 
Smoky City is a matter of no inconsider- 
able moment. But this element has been 
bountifully supplied by the designer, Dr. 
Sutton. The entire front is of glass; 
there is also a large glass plate in the front 
eastern exposure. The floor is of white 
Georgia marble and the walls support a six- 
foot wainscot of the same material. Above 
the marble the walls are finished in lead of 
a delicate blue hue, which is tastefully 
offset by the ceiling in white. On the 
eastern aspect from before backward are 
respectively the glass, a large sterilizing 
gas range embedded in enameled porcelain 
bricks, and a six-foot horizontal slab of 
marble, in which are set three basins; the 
latter is surmounted by a large highly 
polished copper reservoir for hot water. 
The plumbing is in brass, making the beau- 
tiful contrast which is so familiar. 

Adjoining this and connected with it is 
a room of smaller dimensions, finished by 
Mr. S. P. Harbison, also a member of the 
hospital board, in exactly the same manner, 
with the exception that the wainscoting is 
here four instead of six feet. This ad- 
mirable little apartment, is used as an an- 
aesthetizing, dressing and examining 
room. 

The facilities for operating are exquisite. 
The material of the floor and walls permits 
the practice of the most thorough meas- 
ures known for disinfection and the estab- 
lishment of perfect asepsis. 

Since the election of Dr. Sutton as 
Gynacologist to the Allegheny General 
Hospital I have had the pleasure of assist- 
ing him at the following operations at that 
institution : 

Case No, 1. — Ovariotomy. Diagnosis: 
Multilocular cyst of right ovary. Ad- 



mitted to Allegheny General Hospital, 
March 23, 1892. 

History. — Patient Mrs. G., aged 55 
years, had given birth to four children, the 
youngest at that date being something 
over thirty years of age. Family history 
negative. 

Personal history. — ~No history of dys- 
tocia or menstrual disturbance. About one 
year prior to admission to hospital, patient's 
attention was attracted to tumor-like mass 
in lower right abdomen, which rapidly 
grew in size until the (then) present time, 
when she applied for admission to the 
hospital for purpose of having operation 
done. 

Operation March 26, at 9 A. M. Abdo- 
men was laid open from umbilicus and 
cyst delivered after the method of Peon. 
Proved to be cyst of right ovary, multilocu- 
lar, weighing 16 pounds. Pedicle was 
rather broad and was ligated with silk. 
Left ovary was found to be in a state of 
cystic degeneration and was also removed. 
Omentum was adherent to abdominal 
parietes, cyst and intestines had bled freely; 
haemorrhage controlled by silk ligatures. 
Abdomen flushed and closed. Time of 
operation, thirty minutes. 

Patient rallied well ; temperature same 
evening 99 4-5° pulse 104. Eested quietly 
and passed gas during the night. On 
the third day uncontrollable emesis set in 
which became fecal on the seventh day. At 
the appearance of the latter symptom, no 
movement of the bowels having occurred, 
the patient was placed on the operating 
table and an incision made in the left in- 
guinal region, and a protruding portion of 
the ileum stitched to the abdominal wall. 
An incision was then made into the gut, 
which was followed by a very large watery 
evacuation, with much flatus. At this 
time stitches were removed from primary 
wound, union having taken place through- 
out by first intention. The opening of 
the ileum was followed by a temporary im- 
provement in the patient's condition. The 
emesis ceased and she partook of consid- 
erable nourishment and stimulant. Four 
days after, however, the emesis returned; 
patient became exhausted, passed into a 
typhoid state and died on the fourteenth 
day. 

At the post-mortem the ileum, colon 
and rectum were found to be in a condi- 
tion of gangrene. There was no effusion 
or other evidence of inflammation. The 



52 



Communications. 



Vol. lxvii 



theory is advanced by Dr. Sutton that 
gangrene was due to embolism of mesen- 
teric arteries. The emboli being derived 
from a large varix just below Poupart's 
ligament and connected with the femoral 
vein. 

Case II. Double salpingo-oophorec- 
tomy. Diagnosis : Gonorrhoea! salpingitis. 
Admitted to Allegheny General Hospital, 
March 5, 1892. Awaiting operation on 
Dr. Sutton's arrival. Miss 0., aged 19. 
Domestic ; family history negative. Person- 
al history : First menstruated at thirteen. 
Had an attack of gonorrhoea four weeks 
previous to admission to the hospital. 
Examination revealed tenderness over both 
tubes with some enlargement. 

Operation March 26 at 10 A. M. In- 
cision about two inches in length. Tubes 
and ovaries on both sides found enlarged 
and congested. Slight adhesions. Both 
removed. No flushing or sponging of 
cavity. Wound closed with silk-worm-gut. 
Time of operation, twenty minutes. 

Neither temperature nor pulse ever went 
above 100. Three stitch-abscesses formed 
during convalescence, but yielded readily 
to treatment. Patient left her bed on 
twenty-first day in good condition. 

Case III. — Herniotomy. Diagnosis: 
Ventral hernia. Admitted to Allegheny 
General Hospital, March 12, 1892. Mary 
D., aged 27. Married. Domestic. Family 
history negative. 

Personal history: — According to her 
own statement, had right ovary and tube 
removed, with nine inches of intestine, in 
Philadelphia, in the spring of '89, and in 
'91 at the same place, had been operated on 
for hernia, result of first operation. Latter 
operation was unsuccessful. 

Examination revealed protrusions of 
intestine at various points on the abdomen. 
The patient extremely fat and flabby. 
Fasciae atrophied and retracted. 

March 26, 11 A. M. Abdomen includ- 
ing peritoneum laid open. Edges of re- 
tracted fascia secured with buried silk- 
worm-gut sutures. Superficial tissue 
closed with continuous silk- worm-gut 
suture. Wound healed by first intention, 
patient discharged on 21st day. Buried 
sutures afterward suppurated, yielded to 
bichloride irrigation, and the wound is 
now in good condition. The hernia at 
the point operated upon, is entirely re- 
duced — a large protrusion still exists, how- 
ever, above the point operated upon, which 



it is the intention of the operator to at- 
tempt to close at a subsequent operation. 

Case IV. — Double salpingo-oophorec- 
tomy. Diagnosis: Double gonorrhoeal pyo- 
salpinx. Admitted to Allegheny General 
Hospital, March 28, 1892. Operated 
March 26th, at 10 A. M. Incision 
about two inches in length. Tubes and 
ovaries on both sides found enlarged and 
congested. Slight adhesions. Both re- 
moved. No flushing or sponging of cav- 
ity. Wound closed with silk-worm gut. 
Time of operation, twenty minutes. 

Operation March 30, 1892, at 2 P. M. 
After the abdomen was opened the great- 
est difficulty was experienced in loosening 
adhesions sufficiently to expose the uterus. 
This was finally accomplished. The ad- 
hesions were excessively dense and the 
haemorrhage following their separation 
profuse. The right tube and ovary were 
removed first; they were embedded in a 
solid mass of adhesions which were so firm 
that they could scarcely be torn apart. 
After the greatest difficulty they were torn 
off. A similar condition was found to 
exist on the left side, but the adhesions 
if anything were more dense. The ovary 
was removed and what appeared to be the 
remains of the tube. Haemorrhage was 
very severe but was finally controlled. A 
drainage tube was inserted and the abdo- 
men flushed and closed. Time of opera- 
tion forty-five minutes. At midnight, 
temperature was 99°, pulse 104. The drain 
tube was exhausted at 8 P. M., and fgiss 
bloody water removed. Temperature next 
morning was normal, pulse 108. Tube 
being empty was removed at 3 P. M. Pulse 
same evening 108, temperature 991. ° 
About this time the patient became 
maniacally hysterical. Tossed and fumed, 
sang ridiculous jargon, etc. Her abdo- 
men became distended, vomiting set in, and 
after two days of raving which finally be- 
came true delirium she became exhausted 
and died. Temperature at highest point 
was 1001 °F. 

The post-mortem revealed a violent 
peritonitis with small quantity of pus in 
the pelvis. Died April 2, 4.30 P. M. 

Case V. Double oophorectomy and 
anterior fixation of uterus. Diagnosis : 
Procidentia uteri, prolapsed ovaries with 
chronic ovaritis and salpingitis. Mrs. D., 
aged 26, married. Admitted to the hos- 
pital sometime during February and 
awaiting operation at time the operator 



July 9, 1892. 



Communications. 



53 



came on duty (March 26, '92.) Family 
history, negative. Personal history. — 
Gave birth to one child which was " still 
born" probably from the use of instru- 
ments. Her pelvis was found to be badly 
deformed (kypho-scoliosis). At the de- 
livery of this child the cervix and perineum 
were both severely lacerated. The latter 
into the rectum. She had as a result pro- 
cidentia, and coccyodynia with frightful 
erosion of uterus. An operation was done 
by a member of the hospital staff who suc- 
ceeded in closing the perineum. This oper- 
ation did not affect the procidentia, how- 
ever, which returned, the uterus again be- 
coming eroded. Treatment with pessaries 
was tried but only increased , the discom- 
fort. 

On examination March 36, the ovaries 
were found prolapsed and tender and a 
laparotomy was consequently determined 
upon. 

Operation March 31. Ovaries and tubes 
found enlarged and congested and removed. 
Uterus fixed to lower angle of abdominal 
wound by two buried silk sutures. Wound 
closed with silk. Temperature rose to 
1011° on fourth day; also an erratic rise on 
fifteenth day to 1031°. Pulse, however, never 
went above 100. Some stitch abscesses 
formed and buried sutures came to sur- 
face and were removed. Left the hospital 
May 26 completely cured and in perfect 
health. 

Case VI. Double oophorectomy. Diagno- 
sis: Chronic salpingitis, ovaritis and pelvic 
peritonitis. Mrs. P. ; aged 29, married. 
Family history : One aunt died of pelvic 
cancer. Operation April 26. Tubes and 
ovaries on both sides enlarged. Looked 
somewhat suspicious of malignancy. Time 
of operation 55 minutes. Recovered, con- 
valescence uninterrupted. 

Case VII. Ovariotomy. Diagnosis : Mul- 
tilocular cyst of right ovary. Left ovary 
diseased. Admitted to Allegheny General 
Hospital, May 3rd, 1892. Miss M., aged 
20. Family history. Patient, a sister of 
Mrs. P. ; operation May 6. Small cyst of 
right ovary, left ovary cystic. Time of 
operation 20 minutes Recovered, conva- 
lescence uneventful. 

Case VIII. Oophorectomy. Diagnosis : 
Multilocular cyst. Admitted to hospital 
May 5. Mrs. W., age 45. No history. 
Sixteen pound multilocular cyst, pedicle 
five inches broad and tied in sections. 
Recovered, convalescence uneventful. 



Case IX. Double oophorectomy. Diag- 
nosis : Chronic ovaritis. Admitted to hos- 
pital May 6. Mrs. C. aged 26. No chil- 
dren. Operation May 7. Ovaries as 
large as a hen's egg. Both removed. 
Sat up on twelfth day, left hospital on 
19th day. 

Case X. Double salpingo-oophorectomy. 
Diagnosis : Chronic salpingitis and ovaritis. 
Admitted to hospital May 24, 1892. Miss 
H, aged 29. Operation for lacerated 
perineum and cervix performed in spring of 
1890. No relief. Operation May 28, 
both ovaries cystic and large and both 
tubes inflamed. Highest temperature 
1001°. Pulse 90. Recovered. Sat up on 
14th. day, uneventful convalescence. 

Other reports will follow from time to 
time. 



ARISTOL AND EUROPHEN. 
By DR. A. EICHLER, 

PHYSICIAN TO ST. JOSEPH'S HOSPITAL, SAN 
FRANCISCO, CAL. 

When antiseptic methods were first in- 
troduced to the notice of the medical pro- 
fession, there was but little choice among 
the agents useful to secure complete anti- 
sepsis. Carbolic acid and iodoform were 
about the only ones in extensive use ; ob- 
jections regarding their toxic faculties and 
still more regarding their odor were barely 
considered, although often mentioned. 
Since progressive chemists, however, have 
furnished us with almost countless other 
antiseptic agents, and since carbolic acid 
has been largely superseded by the bichlo- 
ride of mercury, those objections, which, 
as already stated, were hardly noticed in 
former days, have continually grown in 
magnitude and are now viewed with such 
seriousness, that the antiseptic which now 
wants to achieve distinction and success, 
must satisfy us not only regarding its 
antiseptic virtue, but also regarding odor 
and innocuousness. 

As iodoform may be called principally 
an iodine compound, and as its germici- 
dal action practically rests upon the iodine, 
it was but natural that chemists should, 
above all, try to form other compounds of 
iodine, which should possess the advan- 
tages of iodoform without its disagreeable 
features. They succeeded in giving us 
quite a number of such compounds, which, 



54 



Communications. 



Vol. lxvii 



however, never rose to the popularity of 
their congener. The first compound suc- 
ceeding in a larger measure than all others 
previously offered was aristol, which was 
first presented about two years ago. It is 
composed of iodine and thymol; chemi- 
cally speaking, it is a di-thymol-di-iodide, 
obtained in the form of a brownish red pre- 
cipitate by treatment a solution of iodine 
and iodide of potassium with an aqueous 
solution of thymol and caustic soda. 
Aristol is insoluble in water or glycerine ; 
in alcohol it is almost insoluble, while in 
ether or chloroform it dissolves very readily. 
If alcohol is added to an ethereal solution, 
aristol will be precipitated. It is also very 
soluble in fatty oils. Olive or almond oil 
are the oils most commonly used for this 
purpose. Oily solutions should never be 
made by heat, as this would produce 
chemical changes. In its dry state aristol 
is of a brick red color, which it also imparts 
to solutions. It decomposes on exposure 
to heat or light ; this decomposition may 
be readily recognized by the change in 
color. It should always be kept in a cool 
place in colored bottles, amber color to be 
preferred. Its odor is but slight and not 
at all disagreeable. It adheres readily to 
the skin, thus adapting it for application 
in powder form. It is not toxic, and is 
in this respect decidedly superior to 
iodoform. If it was toxic, iodine 
could be detected in the urine of patients 
to whom it was applied ; repeated examin- 
ations, however, by means of the starch 
test, have given negative results. In cases, 
where iodoform, having produced consti- 
tutional disturbances, was replaced by 
aristol, no unpleasant effects were noticed. 
Aristol can thus be safely applied to large 
surfaces. 

In practice aristol has been found very 
useful in diseases of the skin, in which it 
proves quite effective without producing 
stains; it is prescribed in much the same 
manner as iodoform. It may be applied 
in its pure state as a powder or its strength 
can be reduced by powdered starch ; it can 
also be made into a paste with starch and 
it is thus shown, that aristol contains no 
free iodine and is a stable compound. As 
it is soluble in ether, it may be added to 
collodion in varying strength and then 
applied with a camels-hair brush. The 
usual strength of such applications is 1 
part of aristol in 10 of the vehicle. For 
ointments, lanoline or petrolatum can be 



used as a base to contain from 5 to 20 per 
cent, of aristol. Suppositories, for rectal, 
vaginal or urethral disease contain usually 
from 1 to 5 grains of the active ingredient ; 
heat must be avoided in their preparation. 
It should also be mentioned, that substan- 
ces possessing strong chemical affinity for 
iodine and thus decomposing the com- 
pound, should not be combined with 
aristol. 

Besides its successful employment in af- 
fections of the skin, aristol has also been 
much used in chronic ulcers, syphilitic 
lesions, in short in all those cases, where 
iodoform has been formerly prescribed in- 
ternally it has been employed very little. 
Iodoform, however, has also never been 
found efficacious when internally given. 

When aristol was introduced it was also 
reported that similar compounds might be 
obtained by replacing the thymol with 
resorcin or salicylic acid ; neither of these 
combinations have ever been presented in 
commerce. Instead of them another rival 
has arisen, in which a cresolate is substitut- 
ed for the thymol, its commercial name 
being europhen; this is a typical example 
of what modern chemistry can accomplish 
in the nature of antiseptic compounds. It 
is formed by the action of iodine on iso- 
butylorthocresol,in presence of alkalies. It 
exists as a fine amorphous, yellow powder, 
insoluble in water, but very readily so in 
alcohol, ether, chloroform or fatty oils, the 
latter taking up almost 25 per cent. Its per- 
centage of iodine in combination is almost 
28 per cent. It is more adherent to the skin 
than iodoform; it is very bulky, so that a 
small amount by weight will cover quite a 
large surface, a fact which constitutes 
quite a saving in expense. It is supposed 
to be 5 times lighter than iodoform. Its 
odor is agreeable, actually quite aromatic. 
Its action is similar to iodoform, depending 
on the gradual liberation of minimal 
quantities of iodine. While europhen is a 
definite chemical compound in its dry 
state, it begins in presence of moisture 
at a degree of heat equal to body heat, to 
liberate iodine, on which its antiseptic ac- 
tion depends ; as this process proceeds 
gradually and as the iodine combines with 
the albuminoid constitutents of the body, 
thus rendering absorption very slow, it is 
almost innocuous. When alkalies are 
present, the liberation of free iodine is 
accelerated. Its solubility in oil allows 
its application in hypodermic medication. 



July 9, 1892. 



Communications. 



55 



As europhen is thus like iodoform in its 
physical properties it is only to be expect- 
ed that their therapeutic indications should 
be similar also. Owing to its comparative 
recent introduction, reports regarding its 
activity are rather few, those published so 
far, however, show that the remedy may 
be confidently prescribed. 

One of its chief applications, if it is 
supposed to supersede iodoform must 
necessarily be to venereal diseases. In con- 
tradistinction to other similar agents 
europhen has proved quite satisfactory. In 
soft chancre it promotes healing rapidly ; as 
it is especially in this affection that pati- 
ents object to the odor of iodoform it is 
quite probable that europhen will be 
universally adopted as the remedy. An 
ointment containing europhen 15 grs. to 
vaseline or lanoline ^ oz will be an ap- 
plication of suitable strength. It may also 
be used as an internal remedy in constitu- 
tional syphilis, instead of other iodine 
preparations and it can also be injected 
hypodermically for this purpose. One 
should then begin with a very small dose, 

1 of a grain and increase slowly to 1 or 

2 grains ; when the dose is increased too 
rapidly iodism in its usual form may 
manifest itself. For the various syphilitic 
eruptions it can be applied in the form of 
an ointment. 

In cases of non- syphilitic affections of 
the skin, especially the parasitic varieties, 
it has not proved itself a very active agent. 
Erysipelas, in its milder forms, is often 
very much benefited by applications of an 
europhen ointment of moderate strength. 
In burns and scalds europhen proves itself 
an excellent topical remedy. It relieves 
the pain almost instantaneously, stimulates 
granulations and leads to the formation of 
an elastic and firm cicatrix. 

It should be applied in ointment form, of 
about 3 to 5 per cent, strength, with either 
a vaseline or lanoline base. Another, also 
very effectual mode of applying it is to 
first cover the surface of the burn with eu- 
rophen and then with a 2 per cent, solution 
in oil; the part affected should be then 
wrapped in sterilized gauze, which is to be 
completely saturated with the europhen 
oil; a piece of oiled silk should be laid 
over this and fixed permanently, with 
either a roller-bandage, adhesive strips or 
a water glass dressing, according to the ex- 
tent and location of the burn. This 
makes an ideal dressing, which will not 



require to be changed often and under 
which exuberant granulations will be pro- 
moted. At the same time, as the oily 
dressing will not adhere to the wound, 
there is no danger of tearing off the gran- 
ulations whenever the wound is dressed, 
and thus delay healing. Quite severe 
burns heal by this method in a very short 
time. 

Europhen also is of great service in 
chronic diseases of the nasal air passages, 
be they caused by hypertrophy or atrophy. 
It can be readily applied by a powder ato- 
mizer, either alone or in combination with 
inert dry powders. 

In urethral surgery it can be used much 
like iodoform; gelatine bougies may be 
impregnated with it. 

Europhen is especially indicated in such 
cases, where a stimulant effect and granu- 
lations are desired; in the treatment of 
chronic ulcers, especially of the indolent 
order, it will probably be still more used 
than iodoform has been. Fistulous tracts 
can, when an operation is not desirable be 
injected with an ethereal or oily solution 
thereof and thus be healed. 

Considering all, we now possess in aris- 
tol and especially in europhen two antis- 
eptic agents, which will answer to all de- 
mands heretofore of iodoform. They are 
somewhat less stable than iodoform, as far 
as the influence of light is concerned; but 
this is no serious objection: in antiseptic 
value they are fully equal to iodoform, 
equally non-irritating, more agreeable and 
less toxic, on account of slower absorption. 
They are useful in all affections where a 
remedy is required to prevent decomposi- 
tion and destroy the bacteria of disease. 



UMBILICAL VEGETATIONS. 

In the treatment of umbilical vegetations, 
Sevestre {Rev. Gener. de Clin, etde Therap., 
April 20, 1892) recommends: 1. Every 
morning the vegetations are covered with 
tannin finely powdered, this being intro- 
duced into all the furrows of the growth 
by means of a stilette. 2. Apply a pad- 
ding and a small bandage. 3. On the 
following days, the crust is removed, a 
warm bath given, and the application re- 
newed. This treatment is to be continued 
until a cure is obtained, which generally 
takes place in the course of 2 weeks at 
most. 



56 



Communications. 



Vol. lxvii 



A CASE OF AN OLD EIGHT INGUI- 
NAL HERNIA, IRREDUCIBLE; 
OPERATION FOR SAME. 



By JNO. B. CRANDALL, M. D., 

STERLIXG, ILL. 



E. J. H., American, age T4 years; 
married ; occupation, proprietor of a livery 
stable. Have known Mr. H., for tlie last 
twenty years; he has always enjoyed good 
health with the exception of an epithelium 
cancer of the right cheek, which was re- 
moved some eight years since. Some four 
years later he had a deep abscess under 
pectoral muscles, which was treated by deep 
incision and syringed out with a solution 
of permanganate of potash. 

The patient had been troubled with an 
old inguinal hernia for years and wore a 
Hubbard truss. Some four or five years 
ago I gave him chloroform, and with the 
assistance of Dr. Keifer we had no trouble 
in reducing the tumor which was then in 
the scrotum, by taxis. Has had more or 
less stomach trouble for the last few years, 
which has been amenable to treatment. 

May 15, 1892, was called just after din- 
ner at 1 o'clock. I found a loop of the 
ileum in the inguinal canal. He said that 
he felt something give way in the morning 
as he was making some exertion to drive 
some fowls from his dooryard. He was 
extremely nervous. Dr. Keifer assisted 
me in attempting to reduce the hernia as 
before, by taxis. We put him fully under 
the influence of chloroform and tried all 
positions and conservative methods with 
no successful results. We then tried the 
local application of ether over the seat of 
the tumor for an hour or more with no 
success. All of our conservative methods 
failed to relieve him. After explaining 
the situation to him and his wife, with 
their consent we called in extra assistants 
at 4 P. M. , and after rendering all of the 
instruments and dressings microbe proof, 
we put him again under the influence of 
chloroform ; cut down upon and pulled out 
the intestine ; removed some old omental 
adhesions; applied some aseptic wash to 
the strangulated parts until they appeared 
to be in a natural state, we then 
enlarged the abdominal opening and 
replaced the intestine in the nat- 
ural bed within the cavity, and 
closed the wound with a double set of 
juniper cat-gut sutures; cut short the 



deep sutures and left them buried. We 
had no trouble from haemorrhage. The 
operation lasted some three-quarters of an 
hour. We dusted iodoform over the 
wound and applied iodoform gauze and the 
ordinary retaining bandage. We then 
placed the patient in a clean bed, and in a 
short time he came out from under the 
influence of the anaesthetic, but had more 
or less nausea. The operation was per- 
formed at four o'clock P. M., three hours 
after first seeing the case. At ten P. M., 
we gave him a small hypodermic injection 
of morphine, which quieted him down for 
the night. For the next three days we 
kept him in a passive state, feeding him 
light broths and to quench thirst, which 
was not excessive, we gave him Apollinaris 
water. He felt no pain at the seat of oper- 
ation but was troubled with nausea, and 
would eject most of the articles taken into 
the stomach, and, at times mostly clear 
bile. This we attributed to the fact that 
just before the operation he took un- 
known to us a dose of cathartic pills. 

Our next move was to get a natural 
movement of the bowels. We gave him a so- 
lution of epsom salts with the different 
mineral waters, which were retained 
for some time, but did not act upon the 
bowels. We then gave him injections of 
different mixtures and succeeded in get- 
ting a passable movement from the bowels 
after giving a copious injection of ox gall. 
The pulse did not run over ninety per min- 
ute, and the temperature was normal. He 
could retain nourishment longer, and the 
wound gave him no trouble. Ten days 
after the operation we looked for a speedy 
recovery, as the incision had healed by first 
intention. But at the end of the two 
weeks the stomach symptoms reappeared; 
he- complained of a burning sensation upon 
taking any fluid. Up to this time there 
had been no apparent tympanites ; all of 
the pain was located in the stomach. He 
could not retain food. We tried enemas 
of beef tea, in order to nourish him by the 
rectum. 

During the last week there was more or 
less gaseous distension of the stomach and 
the upper part of small intestines. We 
were unable to get any further movements 
of the bowels or keep any amount of nour- 
ishment in his stomach for any length of 
time. He had no fsecal vomit at any time 
during his sickness. He lingered along in 
the same way. During the last week we 



July 9, 1892. 



Communications. 



57 



gave him a hypodermic injection of mor- 
phine y& gr. at night, which gave him tol- 
erable rest. He died upon the twenty-first 
day following the operation. 

~No post-mortem was allowed. 

As to the cause for the persistent stomach 
trouble, we attributed it to the action of 
the corroding influence of the bile products 
open the mucous coating of the stomach, 
developing latent cancerous lesion ; or else 
to an invagination of the lower part of 
ileum; or from some bands of plastic ma- 
terial encircling the seat of original strict- 
ure. Knowing the patient to be of a can- 
cerous diathesis, we have reason to attribute 
the stomach trouble to that cause. 



OLEUM TEREBINTHINiE AS A 
REMEDY FOE CROUP, WITH 
A REPORT OE FIFTEEN 
CASES; WITH DISCUS- 
SION.* 

By E. W. KELLOGG, M. D., 

MILWAUKEE, WIS. 

In consideration of this subject, I wish 
at the outset to disclaim any originality in 
suggestion or application of the remedy. 
I have simply followed the suggestion of 
others and recorded the results. 

Turpentine is an old and well known 
remedy, and yet, little if any used in croup 
until within the past two years. It was 
first suggested by Prof. George in 1886. 
As it has but a limited internal use, I 
may perhaps be pardoned for giving some 
of its physiological actions, as detailed in 
therapeutical works. It is a stimulant 
diuretic, antiseptic and expectorant. It 
arrests fermentation and putrefaction, 
and is very destructive to all forms of 
bacteria. 

It diffuses into the circulation with great 
rapidity and is quickly recognized in- the 
breath, sweat and urine. 

It is secreted by the skin, kidneys, 
lungs, bronchial tubes and probably in 
some measure by the mucous membrane 
of the trachea and larynx. 

The bronchial secretions are consider- 
ably increased. Its effect in croup is 
doubtless due to its local action upon the 
respiratory tract during its elimination 
from the system. 

*Kead before the Milwaukee Medical Society, 
May 10, 1882. 



I am well aware that the diagnosis of 
any or all of these cases may be called in 
question and for that reason have omitted 
two cases in which diagnosis was doubtful. 
I do not care to be classed among those 
who see diphtheria or diphtheritic croup in 
every case in which there is a more or less 
extensive deposit upon the tonsils, phar- 
ynx, nasal surfaces, or larynx; but I do 
believe in a specific contagious disease called 
diphtheria, and believe that the majority 
of cases of so called membraneous croup 
are in reality diphtheria and should be 
treated and guarded against as such. 

Whatever may flourish in other parts of 
the city, however much follicular pharyn- 
gitis may pass for diphtheria in cleanly 
houses and among people who observe the 
most ordinary rules of hygiene, the disease 
with which we have to deal among the 
lower classes of foreign population is more 
than pharyngitis and malignant sore 
throat. It is a disease that kills by the 
score as the grim health-office reports will 
show. 

It thrives in uncleanly houses as vermin 
do and is more common among the lower 
classes of European immigrants packed in 
filthy tenements than it is generally sup- 
posed to be. 

Among these people there are many 
cases to which no physician is ever called, 
and these are the invisible causes of many 
more severe cases of pharyngeal and laryn- 
geal diphtheria. 

The aetiology and pathology of croup is 
shrouded in obscurity both in theory and 
practice. Until 1858 when diphtheria 
was prevalent in England, the word croup 
was confined to an acute disease of the 
larynx believed to be non-contagious, but 
much has been done in the past two years 
towards proving its true cause and rational 
treatment. Recent investigations tend to 
show that the cases formerly described as 
true or membraneous croup were in 
reality laryngeal diphtheria or in other 
words, the difference is one of locality and 
not of exciting cause. 

In the majority of these cases mem- 
brane was visible in the throat for several 
days before there were any laryngeal symp- 
toms. 

Case I. — The first case was a Polish child 
two years of age. Had diphtheria 
for four days when croup developed and 
she grew rapidly worse. 

About forty-eight hours after the laryn- 



58 



Communications. 



Vol. lxvii 



geal symptoms began Dr. Walbridge was 
called in consultation. The child was 
cyanotic. The sternum was strongly re- 
tracted with each inspiration. 

We informed the father that the only 
hope for the child was in tracheotomy, 
and that this would be but a possibility. 

He refused to have tracheotomy per- 
formed and Dr. Walbridge proposed to try 
ol. terebinthinse as an experiment, relating 
a successful case in which he had previ- 
ously used it with Dr. Schiller. The child 
was put on drachm doses every four hours 
and on the following morning was visibly 
improved though the laryngeal breathing 
and crowing cough were still marked. On 
the following day she was still better and 
in three days the symptoms of croup had 
entirely disappeared. 

The child remained weak and anaemic 
for a long time but finally made a complete 
recovery. 

Case II. — German boy four years of age. 
One of four cases of diphtheria in one 
room. He developed croup on the fourth 
or fifth day. His pharynx and nose were 
filled with false membrane. He with the 
others had been taking corrosive sublimate 
and iron in alternate doses. This was con- 
tinued and in addition ol. terebinthinse in 
teaspoonful doses every 2 hours. The 
cough was easier after a few doses. The 
retraction of the sternum disappeared. In- 
spiration became normal and he made a 
complete recovery. 

Case III. — A German girl ten months of 
age. When first seen she had no visible 
false membrane. She was in the third 
stage of croup ; cyanotic, greatly depressed. 
She was given brandy and ol. terebinth, in 
alternate hourly doses. She died in twelve 
hours. 

Case IV. — A Norwegian boy five years 
old. Had an attack of diphtheria. Mem- 
brane was confined to tonsils and pharynx 
with a small patch at one corner of the 
mouth. Developed croup on the second 
day. Characteristic cough and inspiration. 
Was gixen oleum terebinth, in drachm 
doses every 2 hours for four days and 
nights. 

The effects of the drug in this case were 
especially prompt and efficient. Although 
the laryngeal symptoms were continuous 
and severe the effects of each dose could 
be seen in slower, easier respiration, and a 
stronger pulse. He made a complete ( - 
covery. 



Case V. — A Polish child four years of 
age. Had been under the care of another 
physician for a week when croup developed. 
A sister died in the same condition the day 
before. I saw him. When first seen his 
respiration was very difficult the sternum 
falling two inches with each inspiration. 
He was given drachm doses of oleum 
terebinthina? every hour for six hours, 
then drachm doses every two hours. The 
following day he complained of some 
stranguary and the turpentine was given 
every three hours instead of every two. 
The stranguary disappeared during the 
day, and on the following day he was so 
much improved that the family discharged 
the doctor. He was on the street three 
weeks later. 

Cases VI and VII. — Polish girls. Two 
of five cases of diphtheria in one room. 
The treatment was not carried out. Five 
successive physicians were called in four 
days and four of the five cases died in- 
cluding the two with diphtheritic croup. 

Case VIII. — German girl four years of 
age. In the third stage of croup. No 
membrane was visible. Had only been 
sick twelve hours. Teaspoonful doses 
were given every two hours alternating 
with brandy but there was no agreeable 
effect and she died within four hours, from 
suffocation. There was no visible sign of 
diphtheritic membrane in this case. 

Case IX. — Three days later was called 
to see a brother three years of age and 
found his throat filled with membrane. 
Four days later it reached the larynx. He 
was put upon the same treatment and took 
eight ounces of turpentine during the next 
few days. Slowly but steadily all symp- 
toms of croup disappeared and he made a 
complete recovery. 

Case X. — German boy six years of age. 
Diphtheria followed by croup. He was 
given drachm doses every two hours for 
nearly forty-eight hours, but there was no 
effect. He grew steadily worse and died 
from suffocation. 

Case XI. — A Polish girl two years of 
age. Four children in the house had 
diphtheria and her throat was covered with 
false membrane. When first seen she was 
breathing with the greatest difficulty, and 
with each inspiration the sternum was 
retracted enough to make a hollow the size 
of a man's fist. The parents positively 
refused to have further medical attend- 
ance as she was expected to die, but they 



July 9, 1892. 



Communications. 



59 



promised to keep up drachm doses of tur- 
pentine every two hours. For four days 
and nights they gave her a teaspoonful 
■every two hours. She made a slow recovery. 

Case XII. — A Polish boy four years 
old. One sister with diphtheria followed 
by croup had died within a week. Every 
inspiration could be heard in any part of 
the house or out on the walk. His face 
was cyanotic and his extremities cold. 
He was given drachm doses every hour dur- 
ing the day and every two hours at night. 
He grew no worse but the improvement 
was but slight for two days when he began 
to improve and made a rapid recovery. 

Case XIII. — Was an Irish girl four 
years of age. Treatment began about 
twelve hours after laryngeal symptoms de- 
veloped and was steadily kept up for 
twenty-four hours but with no benefit. 
She died from exhaustion. * 

Case XIV. — German boy two years old. 
Diphtheria for six days followed by croup. 
Drachm doses were begun early and given 
regularly but there was no visible effect. 
He died in about forty hours. 

Case XV. — Polish child one year old. 
Diphtheria followed by croup. Strong re- 
traction of the sternum, crowing cough, 
and difficult respiration. He was given 
half drachm doses every two hours and im- 
proved from the beginning. The laryn- 
geal symptoms disappeared in three days 
and he recovered. 

To recapitulate. Of the fifteen cases, 
eight recovered and seven died. In all of 
the eight, recoveries croup was the sequel 
of diphtheria of the pharynx. 

Of the seven fatal cases two were not 
given the treatment, in two others there was 
no visible diphtheritic membrane, in the 
three remaining fatal cases, croup was the 
sequel of diphtheria of the pharynx 

In but one case was there any disagree- 
able effect from the remedy, and that was 
a temporary stranguary when 15 drachms 
were given in 24 hours to a boy four years 
of age. 

In all cases it was given in milk. 

In no case was it rejected after it was 
once past the epiglottis. 

It must be remembered that they were 
cases of a disease of which ninety per cent, 
die. 

DISCUSSION. 

Dr. French: I am very glad that a 
remedy has been found that will hit what 



is termed diphtheritic croup, because I 
have generally bid such cases good-bye as 
soon as I have heard that crowing cough. 
I would like to ask in respect to the use of 
this turpentine, have you given a whole 
teaspoonful to a child a year old ? 

Dr. Kellogg: Yes, sir. 
. Dr. French : Did it have any effect on 
the bowels ? 

Dr. Kellogg: No, sir. 

Dr. French: It is hard work to give 
six drops to an adult and have them keep 
it down. I would like to ask another thing : 
What effect has it upon the other mem- 
branes outside of the larynx ? 

Dr. Kellogg : I could not see any effect. 

Dr. French: Hence it would seem to 
me that it is somewhat peculiar in its 
action. It would seem that if it had an 
action in stopping the formation of a mem- 
brane of the larynx or stopping the swell- 
ing of the larynx, at least that it should 
produce the self-same effect on the other 
membranes ; but Dr. Kellogg, do you 
think that all cases of croup that come 
under your hands are diphtheritic, don't 
you believe that there is such a thing as a 
true membraneous croup from a catarrhal 
difficulty ? 

Dr. Kellogg: There may be, but I be- 
lieve the majority of them are diphtheritic. 

Dr. Walbridge: I only want to ask 
one question. I don't know whether I 
understood the doctor properly in reference 
to two of his cases that are included in 
those fifteen. As I understood him in the 
recapitulation, in two cases the treatment 
was not carried out. 

Dr. Kellogg: Yes, sir. 

Dr. Walbridge: Then it seems to me 
that a report of thirteen cases would be 
much more appropriate and much more 
accurate, and that would make the statis- 
tics very much better ; and in fact I do not 
think those two cases belong with the cases 
treated by the method suggested. 

Dr. Kellogg: The children only took 
two doses. Dr. Walbridge saw that first 
case with me. I would like his substan- 
tiation of the child's condition. 

Dr. Walbridge : Certainly if there ever 
was a case that looked as though an open- 
ing must be made somewhere, either 
through this membrane or below it to give 
the child a chance to breathe that was one. 
The time was very short when that must 
be done. The retraction of the sternum 
was very marked and the expiration was 



60 



Communications. 



Vol. lxvii 



as difficult as inspiration, and as the doc- 
tor remarked in relating the case, it seemed 
as though nothing except intubation or 
tracheotomy would be of any avail ; but hav- 
ing seen a case with Dr. Schiller in which 
he suggested that we try the turpentine 
before adopting surgical means, I Conclud- 
ed that that was the last hope, as any 
surgical operation was not admitted in 
this case. 

Dr. Hayes: I feel very glad to hear 
that some remedy is found that will help 
those cases. Some years ago I had some 
experience in this line ; I never saw a case 
of diphtheritic croup that recovered; I 
have performed ten cases of tracheotomy 
and every one of them has died ; I have 
used intubation and corrosive sublimate 
and never saw a case recover; neither have 
L heard of any case in the county in which 
I had practiced and where diphtheritic sore 
throat was prevalent. I never heard of a 
case that recovered with an operation in 
my own or any one's practice. So I am 
glad to hear that a remedy has been found 
that will offer some hope of recovery in 
those cases. Certainly it is a desperate con- 
dition, and my experience has been very 
discouraging. 

Dr. Shimonek : I would like to ask the 
doctor to state what effect turpentine had 
on the membrane itself ? 

Dr. Kellogg: It came off in a dissolved 
condition. 

Dr. Shimonek: I have had quite a lit- 
tle experience with tracheotomy and with 
intubation, but I am sorry to say the 
patients are all dead. I have had six in- 
tubations since I have been in the city and 
every one of the patients died ; I have had 
seven or eight tracheotomies, but every 
one of the patients is dead; I have had 
quite a number where I used turpentine 
and every one died but one, and that one 
died from complication. The child ex- 
pectorated the membrane whole, forming 
a complete cast of the trachea; the mem- 
brane was not reproduced, but there was 
an immense expectoration of purulent and 
very offensive matter ; the child was thir- 
teen years of age and died. I have used 
bi-chloride until the gums have become 
sore and in some cases bloody diarrhoea en- 
sued; with no effect on the membrane. 

Dr. Walbridge: Please tell us the dose 
and frequency of it that you employed. 

Dr. Shimonek: One teaspoonful not 
oftener than every four hours. 



Dr. Walbridge: I believe the secret is 
to give enough turpentine. 

Dr. Burgess: Would you give the com- 
mon turpentine of Merck's ? 

Dr. Walbridge: Merck's is the best. 

Dr. Wurdemann : If my question is in 
order, I would like some explanation of 
the term croup. To what are we to apply 
it; is it a symptom or a disease ? It seems 
to me I have seen some cases of simple 
laryngitis in children in which there are 
unmistakable croupy symptoms, that is to 
say stridulous breathing. Can we not 
have croup in simple laryngitis ? 

Dr. Kellogg: I do not intend to bring 
forward a cure-all for croup. I know it is 
a terrible disease, and I have made a prac- 
tice until we gave this first child turpen- 
tine, if I found a child with strong con- 
traction of the sternum, crowing cough 
and difficult respiration, to tell the family 
I could not do any more for the child ; and 
I never had a single case, I think, when I 
was sorry I made that prognosis ; but I be- 
lieve that if enough turpentine is given, 
that there are cases in which it is of im- 
mense benefit. I believe I have sat and 
watched children die that might have been 
saved if I had given them enough of the 
drug ; and it does not pay to give it for a 
few hours and then stop, but give it in 
large doses and give it continually. In 
one of those cases I went every morning 
and expected to find the boy dead when I 
got there ; you could hear his respiration 
plainly outside of the house, a long drawn 
inspiration ; he was cyanotic, his extremi- 
ties (both hands and feet) were cold ; his 
heart was weak; but he was kept on tur- 
pentine for between three and four days, 
before there was very much benefit, and 
then he made a rapid recovery. The mem- 
brane came off in flakes, mixed with saliva 
and foam. 

Dr. French : I have performed trach- 
eotomy and I have performed intubation. 
I did have one case recover of intubation, 
a girl of 14; and she got nothing inter- 
nally but the old mixture of iron and pot- 
ash. The formation of the membrane 
seemed to stop as soon as intubation was 
introduced and never returned; I never 
saw the membrane afterwards ; previous to 
that, however, I could pick it out of the 
larynx with the laryngeal mirror; but it 
formed so fast that I saw it was no use in 
bothering any longer and I therefore per- 
formed intubation. 



July 9, 1892. 



Society Reports. 



61 



Society IReports. 

STATED MEETING OF THE MEDICO- 
CHIRUEGrlOAL SOCIETY OF 
LOUISVILLE. 



Stated meeting May 27 th, 1892. 

The President, Dr. ¥m. Cheatham, 
in the Chair. 

DISTURBANCE OF CIRCULATION TREAT- 
ED WITH STRYCHNINE. 

Dr. Turner Anderson : — I wish to call 
your attention to this patient. He is a 
teamster and has been doing a good deal 
of hard work for the last two years or 
more. The point I want to call especial 
attention to is the irregularity in the cir- 
culation. His health all the time has been 
quite good; there has been no apparent 
disturbance of the heart, but recently he 
has been suffering very much from head- 
ache. I thought that possibly the trouble 
might be central in the brain, but an oph- 
thalmoscopic examination by Dr. J. M. Ray 
reveals no evidence of a brain lesion, and 
I have not been able to detect any lesion of 
the heart. The patient states that he does 
not use tobacco to excess, smokes probably 
two or three cigars per week, does not ckew 
at all. Drinks largely of coffee. The 
very marked disturbance in the circulation 
has been present for about two months. 
The only treatment has been strychnia in 
one-sixtieth grain doses three times per 
day. 

PULSATING TUMOR. 

Case No. 2 — This little girl about five 
years ago was struck a blow upon the cheek 
with a hickory stick, which was followed 
by a great deal of contusion. I did not see 
the case at the time. After the swelling, 
contusion, etc. had passed off it left this 
pulsating tumor. When I first saw the 
case about a year ago, I could stop the 
pulsation of the tumor by pressing the 
finger upon the blood vessel. There seems 
to be no change in the form or size of the 
tumor since the patient first came under 
my observation, except possibly it is a little 
larger. 

ACQUIRED HYDROCEPHALUS. 

Case No. 3 — The next case I want to 
show you is a case of acquired hydrocepha- 
lus. This case shows that troubles in 
families never come singly. A little girl 



in the family sustained a fracture of the 
lower extremity of the humerus, then 
about four weeks ago at the time I was 
called to attend the case of fracture, this 
child (the case presented) who had always 
been perfectly healthy, developed symp- 
toms of cerebral disease, began vomiting, 
constipation, crying, etc., and the vomit- 
ing has continued. The cause of the 
trouble is intracranial effusion, and is sim- 
ply a result of meningitis that is chronic 
in character and comes under that head 
which would be considered acquired hy- 
drocephalus. I have watched the pro- 
gress of the case, and it is one of consid- 
erable interest to me. 

LACERATED CERVIX. 

Case No. 4 — The next case I will show 
you is a woman upon whom I operated on 
the tenth of April last for lacerated cervix. 
The history of the case is that she was 
married in November, 1890; about'six or 
seven months later she had premature 
labor — a very serious, hard labor — and did 
not get up afterward with any degree of 
satisfaction. In a short time she was able 
to be about the house, but did not regain 
her health. Eour months after the mis- 
carriage, laceration of the cervix was di- 
agnosticated and an operation performed 
by her attending physician for its relief, 
which however was unsuccessful. She 
then took to her bed three weeks after that 
and remained in bed from that time until 
the tenth of April when I performed this 
operation for laceration of the cervix. It 
was a unilateral laceration and there was 
a great deal cicatrical tissue shown in the 
angle of the tear; her symptoms were of 
the gravest kind. She suffered from seri- 
ous reflex symptoms, among others great 
disturbance of respiration. She had suff- 
ered so much from disturbed circulation, 
respiration, and was so greatly depressed 
that a profound impression was being made 
upon the nervous system, and she was los- 
ing her memory ; it was thought that she 
was losing her mind. She was greatly de- 
pressed, not being able to get out of bed 
at all ; had to be carried from bed and 
placed upon the table for operation. Dr. 
Roberts was kind enough to come in and 
look at the operation, and Dr. Pierce ad- 
ministered the anaesthetic. Four silver 
wire^sutures were used and one silk-worm 
gut. The silver wires were allowed to re- 
main in for three weeks. 



62 



Society Reports. 



Vol. lxvii 



The union is solid and everything is as 
perfect as it could possibly be, gradually 
one symptom after another having passed 
off. She has gained very much in flesh, 
and can now walk about without any 
trouble. Before the operation there was 
great difficulty in her co-ordinating powers. 
Menstruation has been restored, she has 
now passed one period satisfactorily. The 
only symptom remaining is a little un- 
steadiness in her walk, which you will 
notice. 

MYOSITIS OSSIFICANS. 

Dr. A. H. Vance : This patient I saw 
for the first time yesterday. It is a very 
rare case, and one of a great deal of inter- 
est. I take it that it is a genuine case of 
myositis ossificans ; the girl is now seven- 
teen years of age ; had acute pain in the 
muscular system, commencing when she 
was quite young. I find the ossific change 
has occurred in the following muscles: 
Quadriceps extensor, left thigh; biceps 
and triceps, right arm; both pectoral 
groups ; both latissimus dorsi and the ver- 
tical muscles of the back. There is also a 
bony growth of ossified muscles about the 
larynx. I have only seen one other case 
of this kind, and the ossification in that 
was not nearly so extensive as this. I told 
this patient if she would come here and 
allow us to examine her, that we would 
consult together and try to devise some 
treatment, either surgical or otherwise to 
benefit her. 

DISCUSSION. 

Dr. Wm. Bailey: From the casual ex- 
amination I gave the young man presented 
by Dr. Anderson, the heart does not reveal 
any valvular lesion whatever. I believe 
the trouble is cerebral. Such conditions 
occasionally arise from the use of tobacco, 
but I doubt if his use has been sufficient to 
cause it. I believe there is no history of 
rheumatism or endocarditis, and I think 
the trouble is of nervous origin. 

Dr. D. T. Smith: I quite agree with 
Dr. Bailey as to the nervous origin, but 
am inclined to doubt that it is central in 
the cerebro-spinal system. I think that 
the case will go on gradually to a fatal ter- 
mination. 

Dr. W. 0. Roberts : Referring to the 
case exhibited by Dr. Anderson, the little 
girl with tumor on the side of her face: 
We, of course, all recognize this as aneu- 
rism; aneurism involving some of the 



branches of the anterior temporal artery. 
It is the second case of the kind I have 
ever seeu , the first being that of a railroad 
engineer who had his head bumped against 
the window of the cab. I do not remem- 
ber just how long this case had been in 
existence before I saw it; pulsation, how- 
ever, was not nearly so distinct as it is in 
the case j)resented by Dr. Anderson. I 
operated upon the man and he got well 
without any trouble. I think Dr. Ander- 
son^ case will have to be operated upon 
soon, or it will burst. The tissues over it 
are getting very thin. 

Concerning the other case — that of 
lacerated cervix — I was fortunate enough 
to witness the operation, and the woman's 
condition is now very different from what 
it was when the operation was performed. 
At the time the operation was done, she 
was exceedingly nervous and hysterical. 
I have never seen such marked results 
follow an operation for laceration of the 
cervix. It was a very large tear, the 
tissues were greatly indurated. Dr. 
Anderson did the most thorough operation 
that I have ever seen; the parting of the 
edges and approximating of the lips of the 
wound were perfect. He followed the 
method of leaving the stitches in for a long 
time. I think a great many cases of fail- 
ure in this operation are due to the fact 
that the stitches are removed too early. 
The best operators are now leaving them 
in two to three weeks. I think the result 
in this case is largely due to the length of 
time the stitches were allowed to remain 
in. 

Dr. Turner Anderson: I will state 
that recent works on this subject advise 
that it is better to leave stitches in for at 
least three weeks. The last stitches are 
often taken out at the office of the doctor, 
the patient being sufficiently improved to 
come to his office. This case has shown 
excellent results all through, restoring 
the woman, who was bedridden for nine 
months, to the care of her house, to her 
home and friends. 

Dr. E. R. Palmer: Referring to the 
case exhibited by Dr. Vance, I would 
suggest that the best thing for this woman 
to do would be to hire out to some circus 
and exhibit herself as "the ossified 
woman,'' — that would be a phase of Gold 
cure that I could most heartily indorse. 
In my opinion no treatment either medi- 
cal or surgical would be of any benefit. 



July 9, 1892. 



Society Reports. 



63 



Dr. AY. 0. Roberts : It is an exceed- 
ingly rare affection. I saw something on 
the subject not long ago in the British 
Medical Journal ; also saw a case about two 
and a half months ago that presented con- 
ditions very much like this, excepting 
that none of the growths were movable. 
This condition appeared in both lower ex- 
tremities and I think in one arm. 

Dr. D. T. Smith: The case presented 
by Dr. Vance is certainly very interesting. 
In the lower animals we find this condi- 
tion known as myositis ossificans is not 
very rare. The Clydesdale and other 
heavy horses of that character, frequently 
have bony growths in the muscles of the 
legs, and I think the cause is some mis- 
direction of the forces in the relation be- 
tween bone and muscle formation elements, 
that has not yet been traced up. 

Dr. A. M. Vance: I would like to 
have somebody suggest some treatment, 
probably it would have to be surgical. 

Dr. H. A. Oottell : I have a distinct 
recollection of attending a show some two 
years ago in Cincinnati, and among other 
things they exhibited what they called an 
ossified man; to all appearances every 
muscle in this man's voluntary system 
(leaving oitt the occular muscles) was in 
the condition I take it this woman's mus- 
cles will be if the process continues. It 
seems to me that a case of this kind is 
hopeless, unless we can arrest the progress. 

Dr. J. G-. Cecil: I would like to ask 
Dr. Vance the history of this case, that is, 
how fast it has progressed, etc. 

Dr. A. M. Vance: I do not think 
you could get the correct history. About 
six months ago while pumping water she 
experienced pain in the right arm. I 
suppose some shifting of the muscles 
caused this and they date the hardening 
process from this time. The mother,' how- 
ever, says the trouble has existed for a num- 
ber of years. 

ACUTE ASCENDING MYELITIS. 

Dr. J. B, Marvin : I will read a short 
history of a peculiar case, which history 
was prepared and handed me by a room- 
mate of the patient: 

"Mr. B. H. M., aged thirty-two years. 
After his fifteenth year, was a man of del- 
icate health though he took extremely good 
care of himself, except that he was a con- 
stant drinker of whiskey, but not to ex- 
cess. When he was about fifteen years of 



age he was thrown from a horse and sus- 
tained an injury which confined him to his 
bed for a number of weeks, and also caused 
partial paralysis of the lower extremities. 
He made a very good recovery from the in- 
jury, though co-ordination was never fully 
re-established. Ever since the injury was 
received he has at times complained of 
pains in the small of his back and hips. 

About five years ago, an eczema, as he 
called it, appeared on his body, and, from 
scratching, he caused a lesion on his leg, 
which developed into a chronic ulcer, last- 
ing two years and healing finally but with 
much trouble. Treatment for the ulcer I 
do not know. 

He had had- according to his own state- 
ment, two attacks of gonorrhoea, the first 
five or six years ago ; second while attend- 
ing lectures here during 1891, from which 
he had not recovered at the time of his 
death. He came to this city February 
first, 1892, appearing to be in very good 
health and continuing so until three days 
before the final attack of paralysis. Dur- 
ing these three days he complained of pain 
in the small of his back, and of soreness 
and stiffness of the muscles of his hips and 
legs with increased loss of co-ordination. 
On the night of the third day he had a 
paralytic attack, while asleep, of the lower 
extremities, and partial paralysis of the 
upper extremities, which gradually became 
complete, except sensation. He was able 
to move his toes for about two days, and 
could move his fingers for a little longer. 
He did not lose his speech until about ten 
hours before death. He lived four days 
after he was paralyzed. He died from loss 
of respiration. 

His grandfather and two uncles died 
from paralysis, also one of his aunts. His 
father and mother are still living. His 
connections on mother's side were all stout, 
healthy people, though nearly all died from 
paralysis. None of his father's people 
died in that way. His father is a weakly 
man, and has a chronic sore leg. 

I saw him in the morning with history 
that he had attended lectures the day be- 
fore, but felt a little dizziness in going up 
the steps. That night he waked up and 
could not move his. legs. The next morn- 
ing early I saw him and he had perfect 
sensation, but loss of motion in both legs, 
and partial loss of motion in the muscles 
of the body ; still he turned himself on his 
hips and moved his arms, though they did 



64 



Society Reports. 



Vol. lxvii 



not move as freely and easily as normal, it 
appeared to me. The paralysis rapidly 
extended, and lie complained of a sense 
of oppression about the chest. His urine 
was passed normally. At first he had con- 
stant desire to pass the fasces, but later lost 
that feeling. The intellect was perfectly 
clear, and about all the pain he complained 
of was a heavy aching sensation about the 
back, which he thought was due to lying 
in bed in one position. This is about the 
history of the case. The paralysis rapidly 
extended involving the respiratory mus- 
cles, and causing death. 

I succeeded in getting an autopsy, but 
was only allowed to take out the cord. Dr. 
Frank performed the autopsy. In the 
lower lumbar region the canal was very 
bloody, there were also under the mem- 
branes two or three segments looking like 
haemorrhage. After several weeks harden- 
ing of the cord sections were made, which 
upon microscopical examination revealed 
evidences of meningitis, probably chronic 
and more recent diffuse myelitis. 

This case seemed clinically to be one of 
Landry's paralysis, though the autopsy 
proved it to be a case of acute ascending 
myelitis, but myelitis that is central gener- 
ally runs a different course from this and 
is attended with much more phenomena. 

HEMIPLEGIA. 

Dr. W. L. Kodman : I saw a case this 
afternoon in which I am in doubt as to 
the diagnosis, and would like to have some 
light thrown upon it. I saw the patient 
who is about fifty-nine years of age, with 
a physician of Jeffersonville, Ind., about 
six o'clock this evening, with the follow- 
ing history: A year ago last Febuary I 
saw the same gentleman two or three times 
during an attack of hemiplegia of the 
right side. The hemiplegia was rather 
complete, but he made a good recovery in 
the course of two or three months. He 
has been uninterruptedly well since that 
time, and it is now nearly a year and a 
half since he recovered from the attack of 
hemiplegia. Yesterday morning his wife 
left him in bed when she got up to go and 
see about the breakfast; in about half an 
hour he came into the dining room ; she 
asked him how he was — said there was no 
particular reason for asking this as he was 
perfectly well the day before. He stood 
perfectly still and stared at her, and said 
that he thought he was going to die after 



she left him in their room. He was not 
able to walk, but his wife and daughter 
helped him to a chair and finally put him 
to bed. In a short time he had a convul- 
sion which lasted about three minutes, 
shortly afterward he had a second convul- 
sion ; about eleven o'clock he had a very 
severe attack, it being the third, After 
this he became comatose, remaining per- 
fectly unconscious for two or three hours. 
There have been no convulsions since ; he 
could use both arms and both legs to-day 
perfectly well. He vomited all yesterday 
and last night; to-day he has not been 
able to retain anything on his stomach; 
until about noon when he drank a little 
mint water. The patient has been out of 
his head since the severe convulsion; he 
did not recognize me when I called, al- 
though I have known the man very well. 
He has no heart trouble, and there seemed 
to be no particular evidence of atheromat- 
ous degeneration in the blood vessels. 
There is no arcus. Left eye was slightly 
turned inward. Urine was passed freely, 
a sample of which I brought home and 
had an examination made, but no albumin 
was found. The patient had no fever; 
pulse was 140 per minute when first seen 
by his physician ; it was 80 soft and regu- 
lar when I saw him. 

I would like to have an expression from 
the members of the Society as to the 
diagnosis — if there is a clot in his brain, 
where is it located? 

Dr. Wm. Bailey: I have nothing es- 
pecial except to say that I doubt about 
there being a clot, else I think from pres- 
sure there would have been paralysis some- 
where. It may possibly have been simply 
meningitis. I saw mention made of this 
case in the daily paper, stating that he 
had been unusually taxed for days past. 
The paper gave the amount of work per- 
formed by him for the last few days. It 
would seem to me to be meningitis, not- 
withstanding there has been no variation 
of temperature. In Bright's disease we 
have a low temperature notwithstanding 
other conditions that would produce fever. 
Fever is not always an essential element in 
the symptomatology of inflammation ; there 
may be counteracting influences which pre- 
vent the variation of temperature. 

Dr. J. B. Marvin: It would seem to 
me that diagnosis would lie between one 
of two things. The first attack was prob- 
ably embolus rather than clot. The sud- 



July 9, 1892. 



Society Reports. 



65 



denness with which recovery occurred and 
the completeness of the recovery would 
rather indicate to my mind a small embo- 
lus instead of clot. The second attack 
would seem to me to be cerebral congestion 
rather than meningitis. The suddenness 
of the attack would in my mind be against 
the idea of meningitis. I would not be 
satisfied with a single examination of the 
urine. Indications are strongly in favor 
of the kidneys being the seat of the 
trouble. 

Dr. D. T. Smith: I perfectly agree 
with Dr. Marvin — of course we must all 
admit that we can only guess at the diag- 
nosis in this case. , 

Dr. W. L. Kodman : The case is by no 
means clear to me. I do not agree with 
Dr. Bailey that it is in all probability men- 
ingitis ; the attack was too sudden for any- 
thing of that kind. Furthermore, the 
history of the case makes it rather improb- 
able for the attack to have been meningi- 
tis. I think the former attack was very 
likely due to a small clot rather than em- 
bolus. I believe that the present attack is 
-either due to congestion as suggested by 
Dr. Marvin, or possibly to a clot not in the 
same situation as the former one, because 
it would produce paralysis, either of 
motion or sensation. Further examination 
•of the urine will, of course, be made. 

LAPAROTOMY. 

Dr. A. M. Oartledge : I have a very 
interesting case to report, it being a little 
unusual in the way of ovarian trouble: 
On the fifteenth of March I was called to see 
;a young married woman, twenty- five years 
<of age with about the following history: 
Three days before that time her sister 
living in the country had married, and in 
preparations for the wedding, she (the 
patient) had done a great deal of wotk, lift- 
ing some very heavy vessels, and various 
other things. She had suffered from con- 
siderable pain in the left side of the pelvis, 
.a, bearing down sensation, ever since the 
wedding occurred. However she came to 
"the city with the wedding party, was put 
up with some of her relatives, and one 
night in going down the steps of the 
stairs she was stricken with severe pain in 
the lower pelvic region, and was put to bed 
which was the occasion of my being called 
to see her. I found her in the greatest 
pain, all evidences of ( marked shock, etc. 
I was at a loss to ascertain the cause of it. 



Simply had to practice the expectant plan 
and gave her a little morphine. The next 
day found her more comfortable; I ex- 
amined her at this time by the bi-manual 
method, but could detect nothing except- 
ing that the pelvic structures seemed more 
or less indurated, and there was great ten- 
derness. She finally became sufficiently 
well to go to her home in the country. 
When her menstrual period came on about 
the fourth or fifth of April, she had a 
repetition of all this suffering, only it 
lasted longer; for three or four days she 
had to be kept under the influence of 
opiates in order to get any relief. The 
pain now was principally in the left side. 
After this menstrual period, she was 
unable to move in bed, could not turn 
from one side to the other. I ex- 
amined her very thoroughly this 
time and detected an induration to the 
left of the uterus rather high up. I con- 
cluded to treat her in bed and see if there 
would not be a decided improvemont in 
another month, or until the next period. 
This was done, and she was never able to 
sit up more then fifteen minutes without 
the pain becoming so severe that she would 
have to go back to bed. The menstrual 
period came again and it was simply a 
repetition of April, again she had to take 
the opiates in order to control the pain. 
After the menstrual period the early part 
of May you could detect by manipulation a 
hard induration in the left pelvis, there 
was also intense pain in that region. A 
laparotomy was performed at the Norton 
Infirmary about twelve days ago, and we 
found that the right ovary was entirely on 
the left side, behind the left ovary, very 
much swollen, twice the size of the left. 
Both the right and left tubes were very 
much enlarged and thickened, and a great 
deal of serum in the tubes ; uterus was 
sunken and more or less retroverted, also 
very much engorged. Both appendages 
were removed. The patient has done well 
since the operation, sleeping better the 
first night without an opiate than she had 
with opiates for several months, 

Dr. 0. Skinner: I would like to ask 
Dr. Cartledge if there was any pus. 

Dr. A. M. Cartledge: There was no 
pus. The tubes were very much enlarged, 
but, I took it,from mal-position. 

Dr. C. Skinner: I am inclined to think 
that the elongation and displacement were 
caused by hydrosalpinx. 



66 



Society Reports. 



Vol. lxvii 



Dr. J. A. Larrabee: I simply rise to 
ask a question for information. It would 
seem that the displaced ovary gave rise to 
all the trouble. I want to ask the surgeon 
whether it would not have been proper, if 
it could have been done, to have replaced 
the ovary without removing it ; that is, if 
that were the cause of the trouble, why 
would not relief have followed correction 
of the position of the ovary without its 
removal ? 

Dr. A. M. Cartledge : I will say in 
regard to Dr. Skinner's remark: It is 
very probable that there was some hydro- 
salpinx. The tubes were very large, and 
very long, and quite red in appearance. 
Probably hydrosalpinx had something to 
do with the trouble at the beginning. The 
question asked by Dr. Larabee would sug- 
gest itself: I did not think we were justi- 
fied in doing a conservative operation, try- 
ing to replace the ovary on account of the 
apparent disease. The safest plan was to 
get rid of the appendages entirely. 

SULPHONAL POISONING. 

Dr. J. B. Marvin: I would, like to 
ask for information : I saw a case a few 
days ago, a gentleman who had taken one 
afternoon and the following morning, in 
divided doses, two doses the first afternoon, 
and three the next morning, sleeping 
pretty well the first night, two-hundred 
and forty (240) grains of sulphonal. I 
know very little about this agent, have 
never given it in larger doses than twenty 
grains. This man went to sleep but he 
never woke up any more. I have been able 
to find out nothing about the toxic effects 
of this drug, nor the antidotes. I did not 
see the patient until some time after he 
had taken the last dose. Found him sleep- 
ing very heavily ; pulse was normal and I 
said let him sleep and we will see what will 
be the result. I did not know at that 
time the enormous quantity he had taken. 
He had taken it on his own prescription, 
telling his wife that it was absolutely harm- 
less, that he could take half an ounce at a 
dose. I found out afterwards that he had 
taken this dose. In the evening at six 
o'clock his pulse was under 1 00, respiration 
32. I could not rouse him from the first, 
pupil responded readily to light. He 
would yawn and stretch himself like a man 
dead asleep, move his hands, lift his head 
up and turn himself in bed. I said to his 
wife that he could not die as long as he was 



in that condition, that we would just await 
developement. Early the next morning, 
much to my disappointment, he showed no 
evidence of coming from under the influ- 
ence of the drug, pulse quicker, respira- 
tion quicker, circulation poor. Still had 
reflex movements, pupils responded to light 
drawing legs up in bed, and would still 
yawn. During the day this became less 
and less, and the pulse went up to 140 or 
more. He passed urine freely until an 
hour or two before he went to sleep. 
Kidneys seemed to secrete until the last. 
I drew off about a pint of urine by cathe- 
terization. The only treatment was nitro- 
glycerines given hypodermatically. 

THE TREATMENT OF TABES DORSALIS 
BY THE METHOD OF BONUZZI. 

In the Revue de Therapeutique Gener- 
ate et Thermale, 1892, No. 2. p. 25, we 
find a clear and concise statement of this 
method, which it is hoped will yield results 
as satisfactory as those attributed to sus- 
pension, without, however, exposing the 
patient to the same danger, nor indeed re- 
quiring the use of any apparatus whatsoever. 
The experiments upon the cadaver have 
shown that the mechanical distention 
undergone by the spinal cord is three 
times as great in this method as in suspen- 
sion. The patient lies upon the back, 
head maintained in an elevated position by 
means of a bolster. The lower extremities 
are flexed upon the body through a semi- 
circle, the knees being placed upon the- 
chest of the patient, the legs being held 
straight ; the operator, seizing the diverg- 
ing ankles, carries them strongly toward 
the floor. The result is, that the vertebral 
column is strongly flexed forward. This 
position must be attained with care, for it 
gives rise to backaches and swellings of the 
posterior aspects of the thighs, due to in- 
tra-muscular haemorrhage. Benedikt re- 
ports a case where attacks of syncope and 
vomiting for many hours, with, adynamia 
for several days, followed this treatment. 
It also has a greater effect upon respira- 
tion and circulation than does suspension ; 
but the distention to which one subjects 
the trunk and limbs can be readily graduat- 
ed, and if necessary, it can be immediately 
terminated. Benedikt reports that the 
gait of the patients was greatly improved, 
and the neuralgias markedly and constantly 
relieved. — American Journal Medical 
Science. 



July 9, 1892. 



Selected Formitlce. 



67 



Selected formulae 



THE CYANIDE AND TRICYANIDE OF 
GOLD IN PHTHISIS PULMONALIS. 

Dr. Oesterlen (Pharmaceutische Zeit- 
schrift fur Russland; Le Bulletin Med- 
ical, No. 101, 1891) recommends the fol- 
lowing formula of the cyanide of gold in 
the treatment of phthisis : 

"D Cyanide of gold cgms. 18. 

-Ljtf Chocolate gms. 45. 

The cyanide of gold presents itself under 
the form of a yellow powder, insoluble in 
water, alcohol or ether. The crystals are 
only recognizable under the microscope. 
This preparation was proposed forty years 
ago by Chretien as a remedy for the treat- 
ment of pulmonary tuberculosis, scrofu- 
losis and amenorrhcea. Later beiug for- 
gotten, it recently has been proposed as a 
therapeutic resource in phthisis. The dose 
is from four to sixteen milligrammes 
several times a day. The tricyanide of 
gold comes in the form of large colorless 
crystals, which are soluble in water and 
alcohol. It has also been prescribed re- 
cently as a remedy in a phthisis. 



SPECIAL TONIC (BELLE VUE HOSPITAL). 

T> Sulph. quinine ■. 30 grains. 

-LV Tinct. nux vomica 160 minims. 

Tinct. chlor. iron 160 minims. 

Dilute phosphoric acid 1 fluid ounce. 

Syrup to make 4 fluid ounces. 

M. Dose, a teaspoonful. 



POMADE FOR CERVICAL CYSTITIS IN 
WOMEN. 

T> Camphorated lanolin SO grms. 

X¥ Ext. belladonna 2 grms. 

M. Sig.— Introduce, morning and evening, into the 
vagina on a wad of cotton. 



TONSILLITIS. 

• Dr. Eloy (Medicinisclie Neuigheiten, 
No. 8, 1892) recommends the local appli- 
cation of salol in the treatment of tonsil- 
litis, and as follows: 

T> Salol gms. 2(grs. xxx). 

JQkJ Alcohol, q. s., ad. sol. 

Glycerine gms. 40 (fl. Sjss). 

For the painfulness in swallowing, gar- 
gle with : 

T>, Cocaine hydrochlorate. mgm. 1 

-Qs (gr. l-64th). 

Glycerine gms. 10. 

(Sijss). 

Or use Huchard's mixture : 

T>, Bromide of potash gms. 5. 

JtV (5dM)- 

Cocaine hydrochlorate mgms. 5. 

Glycerine \ aa gms. 10. 

Peppermint water j (5ijss). 



TREATMENT OF ASTHMA. 

T> Potassium iodide. 
XV Lobelia tincture. 

Senega tincture aa 2.00 grms. 

Opium extract 0.02 grm. 

Distilled water 180.00 grms. 

Sig.— Tablespoonful, mornings and evenings, in a 
wineglassf ul of water. 

— Huchard, Revue Generate de C Unique 
et de Therapeutique; MercFs Bull. 



ANODYNE LINIMENT. 

Camphor 120 grains. 

Chloral 120 grains. 

Chloroform 120 minims. 

Ether 120 minims. 

Tincture opium 60 minims. 

Oil sassafras 60 minims. . 

Soap liniment to make 16 fluid ounces. 



FOR DYSPEPSIA. 

For pain in the chest which comes on 
half an hour or an hour after food, take 
the following: 
Take of 

T> Tincture of nux vomica 10 drops. 

Xjtf Acid hydrochloric dilute 10 drops. 

Chloroform water % ounce. 

Mix, and take immediately after meals. 



TREATMENT OF LUPUS ERYTHEMA- 
TOSUS OF EYELIDS AND FACE. 

Brocq (British Journal of Dermatology, 
1891) recommends in this disease: 

T> Salicylic acid — 5ss. 

-CM Lactic acid 5s«. 

Resorcin gr. xlv. 

Zinc oxide 5ij. 

Vaselin 5xvij. 

The following is also usually' well borne: 

T>. Salicylic acid — 1 part. 

-CX Pyrogallol 2 parts. 

Vaselin 20 parts. 

This is to be rubbed in at night. During the day the 
first named may be applied, the two being thus used con- 
jointly. 



LOOMIS' TONIC. 

Sulph. quinine 15 grains. 

Tinct. chlor. iron 120 minims. 

Spirit chloroform 180 minims. 

Water 1 fluid ounce. 

Glycerin to make 2 fluid ounces.— M. 

Dose, a teaspoonful. 



DANDRUFF. 

Dr. Stephen (Lo Sperimentale, No. 18, 
1891) praises the following: 

T>, Resorcin ) 

iy 01. olivar V aa gms. 10. 

Ether ) 

Alcohol rectificat gms. 200. 

Shak« well and apply with a stout brush. 



68 



Selected Formulae. 



Vol. lxvii 



PURGATIVE INJECTION. 

Dr. Porter (Le Pr ogres Medical, No. 
50, 1891) recommends the following: 

"D. Extr. bil. bovis gms. 25. 

-C¥ Glycerin gms. 100. 

01 ricin gms. 50. 

Aquae. gms. 25. 

Mix with one pint of warm soap and water. 



DIABETES. 

The following mixture is praised by 
Vigier : 

T). Lithii carbonat .30 grains. 

JL¥ Sodii arseniat 1 grain . 

Ext. gentianae 15 grains. 

M. et div. in caps. no. xx. 

Sig.— Take one capsule morning and evening. 



INJECTION FOR OZ^NA. 
The following is Sidlo's formula : 

T>, Potass, chlorati 6. 

XV Glycerini 30. 

Aquas destillat 300. 

M. To be injected, several times daily, in ozaena. 
Small rolls of cotton wet with a solution of glycerin (1 in 
3) are also introduced thrice daily, and allowed to remain 
for one hour each time. 

PRURITUS ANI. 

Dr. Joseph M. Matthews has obtained 
excellent results from : 



T>. Benz. oxide zinc oint. 
XV Campho-phenique 



.55 Sss. 



M. Apply as often as necessary. 

The campho-phenique may likewise be 
used pure, without detriment to skin or 
mucous membrane. 



ECZEMA OF SCALP. 

In inveterate eczema of the scalp Dr. 
Bedford Brown (Maryland Med. Jour.) 
found the following lotion by far the most 
certain : 

t> 01. ricini fSiv. 

XV Bay rum fSij. 

Acid salicyl 5ij. 

Resorcine Si. 

Quinine sulphat grs. x. 

This very active parasiticide is to be applied over the 
«calp night and morning and rubbed into the skin. He 
believes that perseverance in the use of this remedy will 
not only relieve most cases of this kind but will promote 
the growth of the hair. 



OINTMENT FOR HAEMORRHOIDS. 

T> Hydrochlorate cocaine gr. xvj. 

XV Sulphate of morphine gr. v. 

Sulphate of atropine gr. iv. 

Powdered tannin gr. xvj. 

Vaseline gj. 

Essence of rose, q. s. 
Make an ointment and apply to the affected parts 
after each movement from the bowels. It is necessary to 
have the discharges of soft consistency. 

— Journal American Medical Association. 



FOR THE PAROXYSM OF ASTHMA. 
Morphinae sulphat gr. 

SS^^.::::::::::::f«^ 

Sig.— Add to sufficient sterile distilled water, and in- 
ject hypodermatically at the onset of the paroxysm. 



REMOVAL OF EXTRAUTERINE FCETUS 
FIVE MONTHS AFTER TERM: RE- 
COVERY. 

Delaissement (Annales de Gynec. et d' 
Obstet., May, 1892) operated on May 7th, 
1889, on a single woman, aged 20, who 
had become pregnant after the cessation of 
the menses in Febuary, 1888. On Decem- 
ber 13th, 1888, labor pains came on two 
days later the foetal movements ; were 
plainly distinguished, and the heart sounds 
were audible. The cervix was like that of 
a virgin. By December 17th the pains 
had ceased. Afterwards the catamenia 
returned, the foetal cyst remained as a tu- 
mor, resembling a large fibroid, and ex- 
tending to the left hypochondrium. The 
tumor did not press down into the pel- 
vis, the uterus was distinct and pressed 
forwards, and to the left. On May 7th 
the operation was performed. The foetal 
cyst was not adherent to the abdominal 
walls; there was a fluctuating area on its 
upper part. In order to cut off all com- 
munication with the peritoneal cavity, 
sutures were passed through the cyst wall 
on each side of the wound. A brownish 
fluid escaped through the two uppermost 
suture tracts. The cyst was opened be- 
tween the sutures. The foetus lay arans- 
versely, with the head to the left. The 
placenta, very thick, was attached antero- 
inferior^ ; it was as tough as though ma- 
cerated in alcohol, and was not vascular. 
The cavity of the cyst was washed out with 
hot water containing chloroform, and 
dresesd with carboltzed gauze ; a large 
drainage tube was inserted. High tempe- 
rature, with alarming symptoms, followed, 
and did not abate until the fifth day, when 
the placenta began to separate. Delaisse- 
ment believes that the fever was due to in- 
fection of the peritoneum by the two upper 
sutures, and observes that sutures so ap- 
plied should be made to pass along the 
substance of the foetal cyst wall, and never 
across the cavity of the cyst. By June 5th 
all the placenta had come awal\ A year 
after the operation the patient was seen by 
Delaissement : She was in excellent health, 
and the catamenia were regular. There 
was a slight hernial protrusion inferiorly. — 
British Medical Journal. 



July 9, 1892. 



Editorial. 



69 



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Xeatnng Hrtxclea, 

ETHER VERSUS CHLOROFORM AS 
AN ANESTHETIC. 

The subject of this article is truly a 
hackneyed one, yet one in which every 
practitioner of medicine must always feel 
a keen interest. It has not been long 
since every medical periodical both in this 
country and abroad was teeming with ar- 
ticles on the merits and demerits of chloro- 
form — this unusual and general interest 
having been excited by the labors of the 
Hyderabad Chloroform Commission under 
the able leadership of Dr. Lauder Brunton, 
of England. 

The preference given to ether in this 
country and to chloroform in Germany are 
acknowledged facts. The position occu- 
pied by surgeons in other countries has- 
been varying, each of these great anaesthe- 
tics having in turn been credited with the 
greater advantages outweighing their dis- 
advantages. Both, unfortunately, have 
their disadvantages and dangers,, but until 
the ideal anaesthetic has been discovered 
we must be content with what must prove 
the " lesser evil." 

Poignant didactic arguments, based 
upon experimental researches, are always 
both interesting and instructive; and, 
therefore, a brief consideration of one of 
the most thorough and recent contribu- 
tions on this subject may not be without 
good. The writer, Professor Julliard, of 
Geneva, published his paper in a recent 
number of the Revue Medicate de la Suisse 
Romande. " Ether/' says Julliard, " is al- 
most exclusively used by the surgeons of 
the United States and of Lyons, who 
never cease in extolling an anaesthetic so 
much less dangerous than chloroform." 

The statistics gathered show a ratio of one 
death in every 3,258 cases of chloroform- 
ization, and one death in every 14,987 
cases of etherization. The innocuity of 
ether — innocuity compared with that of 
chloroform — is incontestable, and all that 



70 



Editorial. 



Vol. lxvii 



hinders its universal adoption as an anaes- 
thetic are the several inconveniences that 
accompany or follow its use. In order to 
justly weigh the merits and demerits of 
ether, Julliard discusses these singly and 
without bias, and the result is markedly 
in favor of ether. 

What are the disadvantages of ether ? 

First, it is disagreeable to the patient. 
The inhalation of choloform is far more 
acceptable. Yet who, exclaims Julliard, 
would be guided by a question merely of 
pleasantness when it means the employ- 
ment of a drug four or five times more 
dangerous to life? There is undoubted 
force in this arguments but the nausea, 
retching and vomiting so frequently in- 
duced by ether must still be regarded as a 
serious objection, capable of not only de- 
laying the operation but also of weaken- 
ing the patient, and not infrequently 
jeopardizing an ultimate good reaction 
from the operation. 

Second, there is more difficulty in the 
administration of ether, and generally a 
more or less complicated apparatus is re- 
quired. This objection/ according to Jul- 
liard, is really without foundation. In 
truth, while ether inhalers in vogue are 
generally more complicated than the sim- 
ple chloroform inhaler, yet their compara- 
tive complexity neither renders them awk- 
ward nor cumbersome in the hands of an 
experienced anaesthetizer. But apart from 
this, any complicated apparatus can be 
dispensed with. 

Third, ether is less active than chloro- 
form, and its action is considerably slower. 
While acknowledging this to be a fact, 
Julliard does not regard it as an objection, 
but rather as an advantage. In the first 
place, he has observed that even ether in- 
duces anaesthesia within five or six min- 
utes in the majority of cases — surely satis- 
factorily rapid. Again, in such cases in 
which anaesthesia is not as quickly induced, 
naturally a larger quantity of the anaesthe- 
tic would have to be used, be it ether or 



chloroform, and in this event the use of 
the more slowly acting and less powerful 
poison should surely be given the prefer- 
ence. 

Fourth, another objection to ether that 
may be raised, and which has frequently 
been offered by the supporters of chloro- 
form, is that the complete insensibility ob- 
tained by chloroform cannot be produced 
by ether. The experiences of Julliard 
and other writers, however, fail to confirm 
this objection. On the contrary they have 
been able to produce a condition of insen- 
sibility equally as profound as with chlor- 
oform. 

Fifth, it has also been claimed that the 
period of excitation is longer with ether 
and occurs more frequently. This has 
long been regarded by many as a most 
serious objection, but Julliard's experi- 
ments fail to show any appreciable differ- 
ence in the periods of excitement of the two 
drugs. 

Sixth, an objection to ether is its inflam- 
mability. In this respect chloroform has 
undoubtedly an advantage over ether. 
Still, if the lights are well placed above 
the patient, there is nothing to fear when 
the use of artificial light is demanded. 
Julliard has also used the thermo-cautery 
upon the thorax during anaesthetization 
with ether without harmful results. 

Finally, another objection urged against 
ether is its irritating action upon the mu- 
cous membranes; producing cough, saliv- 
ation, and an increased bronchial secretion. 
These unpleasant phenomena, while occur- 
ing occasionally, are not of a serious nature 
and may frequently be greatly lessened or 
entirely overcome by the proper adminis- 
tration of the drug. 

The conclusions of the author, based 
upon fifteen years' experience with chloro- 
form and fourteen years' experience with 
ether, may be briefly summed up as fol- 
lows : 

First, that ether is far less dangerous 
than chloroform. 



July 2, 1892. 



Editorial. 



71 



Second, that the anaesthesia produced 
by ether is equally as complete and pro- 
found as that occasioned by chloroform. 

Third, that the inconveniences of ether,, 
absent in chloroform, may be greatly less- 
ened by a proper administration of the 
drug. 

Fourth, that the only contraindications 
for ether are its inflammability, and its ac- 
tion upon the respiratory mucous mem- 
branes in cases where these are diseased or 
are in bad condition. 

The mask used by Julliard for the ad- 
ministration of ether resembles the simple 
chloroform mask with the following modi- 
fications : the outer portion is covered with 
some impermeable cloth, either mackintosh 
or rubber, to prevent the too rapid evap- 
oration of the drug; it is also sufficiently 
large to permit of free respiration. The 
inhaler, or mask is 15 centimetres long, 12 
wide and 15 deep. 

So much for Julliard's experiences and 
experiments. But he is not alone among 
Swiss and German surgeons in advocating 
the use of ether. Among German physi- 
cians in particular, who for a long time 
almost exclusively used chloroform as an 
-anaesthetic, the gradual change of feeling 
is most marked. G-arre, in the Miinch. 
Med. Wochenschrift, gives the results of 
his experiments with both anaesthetics in 
a large number of cases, and heartily en- 
dorses the use of ether as a surgical anaes- 
thetic in preference to chloroform. In 400 
surgical cases in which ether was used as 
an anaesthetic, he observed that in those 
patients suffering from an organic lesion 
of the heart the drug was well borne and 
even exerted a beneficial action upon the 
affected organ; while in cases of respiratory 
troubles the irritative properties of ether 
rendered its use very objectionable. He 
concludes, therefore, that ether is prefer- 
able to chloroform in patients suffering 
from cardiac troubles ; but on the contrary 
that chloroform is preferable to ether in 
cases of bronchial catarrh and similar affec- 



tions. G-arre found that anaesthesia occurs 
on an average in about four minutes, and 
that about 80cc. are required to maintain 
anaesthesia for a half an hour. 

Dr. Frieter, in a recent issue of the 
Deutsche Zeit. fiir Chirurgie, also pleads 
the cause of ether as a general surgical 
anaesthetic; and Dr. Butter, in the Archiv. 
fur Klin. Chirurgie, speaks most highly 
of ether as a substitute for chloroform in 
general surgery. 

A great advantage of ether over chloro- 
form, as recently pointed out by these in- 
vestigators, is the rapidity with which 
patients recover from the effects of ether 
as compared with chloroform. Death from 
anesthetization syncope, they also claim, 
will almost be unknown should ether be 
used instead of chloroform. 

Thus an anaesthetic, the superior merits 
of which have long been recognized by 
the surgeons in this country, is now only 
gradually asserting its claims among our 
professional brethren abroad. 



ACETONEMIA. 

From a clinical and experimental study 
of the subject, Boesi (Riv. di din. et te- 
rap. Rev. Intern, de Bibliog. Med., 
April 25, 1892) has drawn the following 
conclusions: 1. Acetonaemia exists in the 
physiological state, as has been sustained 
byJacksh, Baginski, and others, its amount 
fluctuating from 12 to 15 milligrammes. 
It does not become a pathological process 
until it has passed this quantity. 2. An 
experimental acetonaemia can be produced 
by the administration of agents which es- 
pecially destroy the blood, such aspyrodine. 
A lack of oxygen in the blood is an auto- 
intoxicating cause of acetonaemia. Patho- 
logically, the condition is observed in ma- 
larial anaemia, in catarrhal icterus, in the 
febrile acetonemic state whose cause re- 
sides in the destruction of the blood-cells 
and the albumin of the tissues themselves. 
3. The acetonemia of intestinal origin is 
not dangerous, but it has of late been ex- 
aggerated. The diminution in the alka- 
linity of the blood is not the cause of ace- 
tonemia, but a phenomenon belonging to 
the order of the auto-intoxications. 



72 



Book Reviews. 



Vol. lxvii 



Book Reviews. 



DISEASES OF THE EYE. A Hand-book of 
Ophthalmic Practice for Students and Practi- 
tioners. By G. E. de Schweinitz, M. D. , Pro- 
fessor of Diseases of the Eye in the Philadelphia 
Polyclinic ; Lecturer on Medical Ophthalmology 
in the University of Pennsylvania; Ophthalmic 
Surgeon to the Philadelphia Hospital, and to 
the Children's Hospital and Infirmary for 
Nervous Diseases. 216 illustrations and 2 
chromolithograph plates. Philadelphia: W. 
B. Saunders, 1892. 

No one who is at all interested in the 
study of ophthalmology can fail to appre- 
ciate this latest contribution to the stand- 
ard text-books on this subject. Close 
observation, a keen sense of appreciation, 
an association with the best minds engaged 
in the study of ophthalmology in Philadel- 
phia, a rich practical experience, together 
with careful study, have eminently fitted 
the author of this admirable work to give 
us the best American text-book that has 
been published in this special field of med- 
ical science. 

A critical reading aided by a comparison 
with other standard works of the kind 
convinces us that it is destined to fill a 
prominent place among the standard works 
upon diseases of the eye. It is pre-emi- 
nently a book for those wishing a clear yet 
comprehensive and full knowledge of the 
fundamental truths which underlie and 
govern the practice of ophthalmology. 
The author has kept well in view his pur- 
pose in preparing the book. 

It is seldom that we find greater clear- 
ness of expression, combined with a grace- 
ful and pleasing style, than is here shown 
in the elucidation of general optical prin- 
ciples, methods of examination, symptom- 
atology and diagnosis. Everywhere the 
text has been systematically arranged ; this 
is particularly true of the description of 
the symptom-groups, which include under 
minor headings the variations caused by 
the different grades or types of the same 
pathological state. The section devoted 
to the consideration of general optical 
principles is excellently adapted for the use 
of students; being clear, concise and 
finely illustrated by appropriate diagrams. 

The chapter upon refraction is contrib- 
uted by James Wallace, M. D., and it is 
of such excellence that it creates a wish 
that it had been expedient to make it more 
extended. The author's long experience 
in the eye department of the University 



of Pennsylvania Hospital is itself evidence 
that this portion of the work has been in 
competent hands. 

The section upon retinoscopy was con- 
tributed by another able ophthalmologist, 
Dr. Edward Jackson, Professor of Oph- 
thalmology in the Philadelphia Polyclinic. 
It is needless to say that this part of the 
book is also exceedingly well done. 

Taken together we think that with such a 
clear and most excellent exposition of the 
principles of ophthalmology, written by 
such entirely competent men, there will be 
little need for European text-books upon 
this subject; for while symptomatology,, 
diagnosis, and technique of the examina- 
tion of the eyes have received the largest 
consideration, neither pathology nor treat- 
ment have been neglected. It justly may 
be pronounced a complete statement of 
the essential facts of ophthalmology. 

periscope* 



THERAPEUTICS. 



FACIAL NEURALGIA. 
Dr. Stewart thinks hypodermic injec- 
tions of ergotin in facial neuralgia to be 
superior to aconite or gelsemium. Gener- 
ally one injection is sufficient, but some- 
times two or even three may become neces- 
sary. — The Medic. Anal. Gaceta Medico, 
Catalana, 10, 1890. 



MICROCIDINE IN URINARY ANTISEPSIS. 

Although there are many antiseptic 
remedies useful in the treatment of dis- 
orders of the urinary tract, Mabboux 
(Lyon Med., April 3, 1892) prefers, in 
the application of direct and indirect anti- 
sepsis, the employment of microcidine? 
which, as is well known, is composed of 
naphtol and caustic soda. The solution of 
this remedy is, according to the author, 
sufficiently efficacious for all manner of sur- 
gical antisepsis. It does not produce pain 
in the urethra nor in the bladder. In 
cases of cystitis, washing with microcidine 
are more advantageous than those in which 
boric acid is employed. The medicament 
is easily tolerated by the stomach, in doses 
of 2 grammes a day, producing good 
results. In direct antisepsis microcidine 
is not superior to salol, but it may be em- 
ployed in patients suffering from album- 
inuria and other diseases of the kidneys, 
without causing untoward effects. 



July 9, 1892. 



Periscope. 



73 



POISONING BY ATRACTYLIS GUM- 
MIFORA. 

This plant belongs to the order of the 
Composite and is supposed to be of an 
edible nature. It has bitter and narcotic 
properties resembling those of poisonous 
mushrooms, and, like digitalis, is said to 
possess cardio-vascular powers. Two 
fatal cases of poisoning by atractylis are 
reported by Oourcenet {Arch, de Med. 
Milit., April, 1892). The symptoms ob- 
served were as follows: Pain in the 
stomach; great, burning thirst; vomiting; 
profound depression ; muscular relaxation ; 
loss of consciousness, and death by coma, 
but without convulsions. At the autopsy, 
there were found ecchymosis on the walls 
of the stomach, and hemorrhagic foci in 
the kidneys ; the blood was of a dark color 
and of a liquid consistency; sanguinous 
stasis in the abdominal viscera, the liver, 
and the cortical substance of the kidney. 
There were no lesions of the respiratory 
organs or of the nerve centres. The author 
points out the necessity, in medico-legal 
cases, of looking for the poison in the 
contents of the digestive tract, and especi- 
ally in those of the stomach and the in- 
testines. 



GLYCERINE IN HEPATIC COLIC. 

At a meeting of the Paris Academy of 
Medicine on March 8th (Sem. Med. -, March 
9th, 1892), Ferrand read a paper on the 
treatment of hepatic colic by glycerine. 
The following are his conclusions: (1) 
G-lycerine given by the stomach is absorbed 
unchanged by means of the lymphatics, 
especially by those passing between the 
stomach and the hilum of the liver and the 
gall bladder. (2) It is a powerful chola- 
gogue and a valuable remedy in hepatic 
colic. (3) In relatively large doses — 20 to 
30 grammes — it brings an attack to an end. 
(4) In small doses — 5 to 15 grammes — 
glycerine taken every day in a little alka- 
line water prevents fresh attacks. (5) 
Without being a lithontriptic, glycerine is 
the remedy par excellence for biliary lithia- 
sis. — Brit. Med. Jour. 



THE DANGER OF COUNTER-IRRITATION 
IN LOCALISED TUBERCULOSIS. 

According to Parrachia Anacleto, coun- 
ter-irritation in localised tuberculosis is 
attended with great danger. Miliary tu- 
berculosis spreads so rapidly from one 



organ to another by way of the veins and 
lymphatics that any irritation set up at the 
seat of the primary mischief cannot fail to 
increase the tendency of the disease to 
become general. Four cases which have 
recently come under his notice show this 
in a remarkable degree. Tuberculosis pro- 
gresses slowly, but it allows of no violent 
remedies, and he thinks, until some method 
of treatment more successful than either 
the injection of tuberculin, or cantharidate 
of potash, or the application of blisters has 
been discovered, the danger of causing 
general infection by their adoption will 
still remain. — Lancet. 



ACTION OF CAMPHORATED OIL. 

At a meeting of the Societa Lancisiana 
degli Ospedali di Roma on February 13th 
(Gazz. d. Osp., March 8th, 1892), L. 
Taussia stated that he had used camphor- 
ated oil with good results in many cases of 
influenza in which collapse from cardiac 
paralysis appeared to be imminent, and in 
pneumonia, typhoid, etc. He gave the 
drug dissolved in oil of sweet almonds in 
the strength of 1 to 2, and sometimes 4 to 
5 per cent. Essence of peppermint was 
useful in disguising the taste. Liberal 
doses (2 to 4 grammes per diem) were 
always given; the remedy was always well 
borne, and no disagreeable effects were ob- 
served. The remedy should be given be- 
fore the patient is in extremis, when an 
active stimulant and expectorant is re- 
quired, and when it is not contraindicated 
by the existence of great cerebral excite- 
ment. In cases of pneumonia, broncho- 
pneumonia, and typhoid fever, the drug 
produced increase of arterial pressure, freer 
expectoration, and a feeling of physical 
well-being which lasted a considerable 
time. Taussia insists that only the best 
Japanese camphor should be used, the 
artificial preparation having, according to 
him, no therapeutic value. — Brit. Med. 
Jour. 



PHENACETIN IN GONORRHEAL 
RHEUMATISM. 

Dr. Rifat {Norsk Magazin for Loegevid- 
enskaben, No. 5, 1891) relies upon phena- 
cetin in large doses when the salicylate of 
soda, iodide of potash and antipyrin fail. 
The first day one may give one gramme 
three times daily, then increase the dose 



74 



Periscope. 



Vol. lxvii 



until six or eight grammes (1^-3 5) are 
taken in a day. The patient must be watched 
for signs of poisoning — dyspnoea, cyanosis, 
vomiting, etc. 



A NEW TREATMENT OF ACUTE GONOR- 
RHOEA, 

Cotes and Slater {Lancet, London, Feb- 
ruary 27, 1892) describes a new treatment 
for acute gonorrhoea. The patient is first 
made to micturate, and thus remove as 
much discharge from the urethra as pos- 
sible. The endoscope tube, warmed and 
oiled, is then passed into the urethra, the 
patient lying on a couch. As a rule, the 
passage of the instrument gives rise to 
but slight pain, but occasionally, in sensi- 
tive patients, a ten per cent, solution of 
cocaine, previously injected into the 
urethra, will be found useful. The ure- 
thra is then thoroughly mopped with dry 
cotton-wool, fixed in a stilet, and exam- 
ined by the electric light. The exact 
limit of the inflammation can be clearly 
seen. It is, as a rule, quite five inches 
from the meatus ; it may be four as early 
as the third day. The implicated surface 
is at once to be recognized by its swollen, 
bright-red appearance as contrasted with 
the rosy color of the healthy urethra. It 
is important not to pass the endoscope 
needlessly far back of the posterior 
limit of the inflammation, which is usually 
sharply defined. The diseased membrane 
should now be carefully mopped again so 
as to remove every vestige of secretion. A 
mop of cotton-wool, on a stilet, charged 
with a solution of nitrate of silver (10 
grains to the ounce), should be pushed 
through the endoscope tube and out the 
distal end. The tube and the mop are 
then simultaneously withdrawn. For the 
two inches of urethra near the meatus a 
fresh mop is used, so as to completely 
saturate this part, where the disease com- 
mences, and the inflammation is most in- 
tense. Patients generally complain of 
slight pain afterward, which, however, 
passes away in the course of ten minutes. 
The patient' is recommended to take a hot 
bath that night and remain in bed the 
following day. A saline purgative and an 
alkaline or copaiba mixture are given in- 
ternally. From four to six times daily 
the patient should use a simple cleaning 
injection — say Condy's fluid, (one drachm 
to the pint). The forty-cases treated in 



this manner have been cured in a little 
over twelve days ; a few cases had lasted 
for some days, and some were associated 
with chordee. 

The principal points of this treatment 
are : 

(1) The urethra can be cleansed so that 
the application comes directly in contact 
with the diseased membrane. 

(2) The extent of diseased surface may 
be seen. 

(3-) The remedy is applied when the 
urethral walls are stretched, so that all 
furrows are obliterated. 

They think that nitrate of silver is the 
best of all injecting fluids, from the fact 
that, in the strength of 1 to 2,000, it kills 
the organisms and produces very little irri- 
tation, and at the same time exerts a heal- 
ing influence on the inflamed membrane. — 
Univ. Med. Mag. 



MEDICINE 



INFLUENCE OF STOMACH WASHINGS ON 
THE ASSIMILATION OF NITROGEN- 
OUS ARTICLES OF FOOD. 

In a very interesting thesis, J. A. Ouar- 
off, (Wratch, No. 51,1892, Bull. Gen. de 
Therap., March 30, 1892) discusses this 
important practical point. The observa- 
tions were made in five patients; 3 of 
whom were suffering from chronic catarrh 
of the stomach, and two with catarrh 
accompanied with dilatation of the organ. 
Five other observations were made on 
healthy individuals. Each experiment 
lasted 16 days, and comprised 2 periods of 
8 days each, one of these with, and the 
other without the washings. Upon 
healthy persons the washings improved 
the assimilation of the nitrogenous sub- 
stances in the following proportions : maxi- 
mum, 3.75 per 100; minimum, 0.47 per 
100; medium, 2.21 per 100. In 3 patients 
the assimilative powers were increased 
also, in the proportion of 2.79 per 100, 
for the maximun: 1.67 per hundred for 
the minimum, and 2.39 per 100 for the 
medium. In 2 patients the assimilation 
was diminished; in one, 1.13 per 100; in 
the other, 1.33 per 100. This diminution 
depends upon the retention of the liquid 
in the stomach. According to the author, 
the washing out of the stomach improves 
the function of the organ, diminishes 



July 9, 1892. 



Periscope. 



75 



stagnation and fermentation, and increases, 
reflexly, the activity of the biliary and 
pancreatic secretions. Under the influence 
of the treatment, the bodily weight and 
the forces of the patient increase, showing 
the favorable action which the stomach 
washings exercise on nitrogenous assimila- 
tion. 



HYSTERICAL ARYTHMIC CHOREA. 

From an interesting thesis, published 
this year, by Dettling {Rev. gener. de Clin, 
et de Therap., April 20, 1892), the follow- 
ing conclusions are drawn: 1. The theory 
regarding the co-existence and simulta- 
neous development of Sydenham's choreas 
and hysteria, may hold good in certain 
cases, but exceptionally so. 2. The hypo- 
thesis which makes of common chorea a 
modification of hysteria, and which is 
based on very uncertain points, is rejected 
by the author. 3. The theory admitted 
by the French observer is that by which 
hysteria may simulate the arythmic move- 
ments of common chorea, producing a 
pseudo-chorea of a Sydenham type, and 
which he calls a hysterical arythmic chorea ; 
but there is no such a thing as a Sydenham 
chorea of a hysterical nature. The hys- 
terical arythmic chorea may, therefore, be 
placed under the same category as that of 
the pseudo-scleroses and hysterical pseudo- 
tabes. Hysteria may give rise to the pro- 
duction of a quite marked common chorea, 
but this arythmic chorea is to be differen- 
tiated from Sydenham's chorea. Its onset 
is sudden, and exhibits a variety of hys- 
terical symptoms. Its duration is similarly 
various ; it always gets well, spontaneously 
often, and frequently relapses if it occur. 
It ought to be looked upon as a prolonged 
attack of paroxysmal hysteria. The treat- 
ment should be of a tonic nature. Anti- 
pyrine has given good results in many 
cases. 



MERCURIAL GASTRO ENTERITIS. 

In an experimental research, P. de 
Michele (Rivista Olinica et Terapeutica, 
Naples, XIV, No. 2, 1892) has endeavored 
to determine the nature of the lesions pro- 
duced in the digestive tract, under the 
action of mercury, and which of those 
lesions are the least dangerous. The ex- 
periments were made on rabbits, and the 
modes of administration of the drug were 



such as are serially pointed out presently. 
No lesion was observed in the first series 
of experiments, while in the rest, the drug 
was found capable of producing a rapid 
and serious fatty degeneration of the mu- 
cous glands: 1. Hypodermatic or paren- 
chymatous injections of calomel, accord- 
ing to the method of Sarenzio. 2. Albu- 
minate or tannate of mercury by the stom- 
ach. 3. Injections of the albuminate, 
according to the formula of Miahle. 4. 
Internal administration of the protiodide 
of mercury. 5. Injections of corrosive 
sublimate. 6. Van Sweiten's solution or 
simple solution of corrosive sublimate by 
the stomach. 



TEMPORARY DYSPNCEA CAUSED BY A 
TUMOR OF THE NECK. 

The following case is reported by Per- 
gens (Archivos Internationales de Rinolo- 
gia, No. 14, 1892) : A country farm-boy, 
16 years of age, had a tumor situated on 
the superior portion of the right side of 
the neck. He complained of aphonia 
every time a current of air struck him, 
and also of a sensation of constriction in 
the throat. On examination there was 
observed a distention of the skin at the 
superior part of the right side of the neck, 
and at the maxillary angle about two centi- 
metres from the protuberance of the chin. 
The laryngeal mirror revealed nothing 
abnormal. During the condition of apho- 
nia there was no change noticed externally, 
but in the larynx only the left vocal cord 
could be seen ; the right cord was hidden 
behind a rounded protuberance, covered 
by a normal mucous membrane. After a 
few days, this condition disappeared ; the 
voice came back and the intra-laryngeal 
swelling was greatly diminished. By an 
operation, the glands and the hypertropied 
submaxillary gland were raised. After 
this, a cure was effected and the symptoms 
of aphonia never returned. These symp- 
toms were attributed to an inflammatory 
process, being produced by the action of 
cold upon the diseased ganglions. 



DILATATION OF THE GLOTTIS IN LARYN- 
GISMUS STRIDULUS. 

Dilatation of the glottis, a valuable means 
to combat the spasm of the organ, should 
be employed in the symptomatic treatment 



76 



Periscope. 



Vol. lxvii 



of the malady under consideration. The 
procedure consists in the introduction into 
the orifice of the glottis of a dilator with 
parallel branches ; pressure should be made 
three or four times, and when the mucosi- 
ties have been expelled the instrument 
should be removed. In a case reported by 
Constantin Paul (Societe de Therapeuti- 
que, February 10, 1892) the spasm ceased 
immediately. For a few moments the sib- 
ilant respiration and the access of op- 
pression were, noticed; but the child was 
able soon after to suckle. 



SURGERY. 



THE SURGICAL TREATMENT OF GRAN- 
ULAR LIDS. 

Darier, the chief of Abadie's Clinic in 
Paris, contributes an article in the Archiv. 
d' Ophthalmologic, February, 1892, con- 
cerning the treatment of granular lids, 
which has been found efficacious in this 
service. The following points are insisted 
upon : 

(1) Anaesthesia with chloroform is in- 
dispensable in every case. (2) One of 
the most important conditions for the 
success of the operation is the complete 
eversion of the eyelids by means of special 
forceps, so that all points of the conjunct- 
ival cul-de-sac may be laid bare and sub- 
mitted to grattage. (3) In order to at- 
tain this object it is very often necessary 
to enlarge the palpebral slit by incising 
the outer canthus and thus facilitating the 
exposure of every portion of the conjunct- 
ival cul-de-sac which is in the least af- 
fected with granular infiltration. (4) 
Scarifications are performed with the ob- 
ject of making the contents of the granu- 
lations apparent with the least destruction 
of the conjunctiva. (5) By means of a 
sharp scraper, and then of a brush com- 
posed of short, hard hairs, all morbid tis- 
sue is scraped and brushed as completely 
as possible. (6) An energetic and pains- 
taking cleansing of the surface with a 
plug of cotton dipped in a sublimate solu- 
tion, 1-500, ends the operation. 

During the first day, iced compresses are 
applied and frequent lotions of sublimate 
solution, 1-2000. The patient should be. 
examined daily, the eyelids everted, any 
sloughs detached, and the whole surface 



thoroughly cleansed with a sublimate solu- 
tion, 1-500. At the end of fifteen days 
the conjunctiva presents a smooth, though 
somewhat tumefied, appearance, but granu- 
lations are invisible and there is no longer 
any secretion. In the event of the pre- 
vious pannus, or other corneal complica- 
tion, the improvement, dating from the 
first day of the operation, is stated to be 
surprising, and in the judgment of the 
reporter there is no treatment which has 
given such good results in so short a time. 
He attaches great importance to the reg- 
ular use of a strong solution of sublimate, 
and recommends that the patients be 
watched for a month or two after the 
operation, and prompt interference be un- 
dertaken in case the smallest trace of the 
former disease should reappear. — Ther. 
Gaz. 



HERNLE OF THE LARGE INTESTINE. 

Gangolphe (Lyon Med., January 17th, 
1892) describes a case of hernia of the 
large intestine, from a consideration of 
which he makes the following generaliza- 
tions: (1) Herniae of the large intestine 
may be accompanied by an appendicitis in 
the hernial sack. (2) The localization of 
the inflammatory troubles to the hernia, 
the appearance of the foetid suppuration 
without issue of gas or of solid matters, 
without serious functional troubles of the 
intestines, may perhaps in the future help 
in the diagnosis of this complication. (3) 
The radical cure, undertaken after a suffi- 
cient delay, is rendered particularly diffi- 
cult, both by the adhesions which form 
and also by the difficulty experienced in 
recognizing the presence of the intes- 
tine. (4) As a general rule the necessary 
incision should be made along the antero- 
internal parts of herniae, for in this way 
wounding the large intestine, should this 
be present, will be avoided. — Brit. Med, 
Jour. 



OBSTETRICS. 



DETERMINATION OF SEX. 

The Dublin Journal of the Medical 
Sciences for March, quoting from La Sper- 
imentale, says that ci Dr. Serrano Monta- 
nel, of Valparaiso, read a paper before the 
last Chilian Medical Congress on the pro- 



July 9, 1892. 



Periscope. 



77 



creation of either sex at will. After four 
years' observation, he had satisfied himself 
that we can pronounce upon the sex of an 
unborn foetus if we know the number of 
menstruations which had occurred be- 
tween the preceding delivery and the 
present pregnancy. If between the birth 
of one baby and the conception of the next 
.an even number of menstruations have 
taken place, the second will be of the same 
sex as the first ; if an uneven number, of 
different sex. This theory assumes the 
identity of menstruation and ovulation, 
which few accept, and also that ova dis- 
charged are of alternate sexes. 



PHOCOMELOUS INFANT. 

Martin Saint- Ange (Jour, de VAnat. et 
de la Physiol., No. 5, 1891) records a 
-case of phocomelous monster with inter- 
nal anomalies ; the notes and description 
were found by Duvernet, and were pub- 
lished posthumously. The mother, aged 
33, had previously given birth to two well- 
formed children. During her third preg- 
nancy she had suffered from syncopal at- 
tacks and excessive irritability, alternating 
with melancholia. Foetal movements were 
first felt at the sixth month, #nd were always 
very feeble. Labor occurred spontaneously 
at the ninth month, the breech presented, 
and delivery soon followed. There was 
some fibroid thickening of the placenta. 
The infant, which was living during labor, 
was born dead ; it was of ordinary dimen- 
sions with the exception of the limbs, 
which resembled those of an embryo of a 
few months. There was symmetrical pho- 
comely; each extremity terminated in six 
digits, which were very short and webbed ; 
the bones of the carpus and tarsus form- 
ed an irregular mass ; the two leg bones 
were united ; the femora were nearly shape- 
less, and the humerus was normal in form 
but fused to the bones of the forearm. 
The heart was situated transversely, the 
foramen ovale was very large, as was also 
the ductus arteriosus, and there was a left 
superior vena cava, as well as the usual 
one on the right side. There was a large 
cleft of the palate, and the tongue, which 
was very small, was firmly fixed by a very 
short fraenum. There were curious mam- 
millated projections on the margins of the 
jaws. The right testicle was in the iliac 
fossa, the left in the scrotum. The penis 



was very small, and consisted of an imper- 
forated glans and a divided prepuce. The 
urethral canal did not exist, but a duct 
passed from the inferior and posterior part 
of the bladder to the anal extremity of the 
rectum. This arrangement resembled that 
found in the monotrematous mammalia. 
A maternal impression was alleged as the 
cause, but, as it occurred late in pregnancy, 
this theory could not be entertained. — 
Brit. Med. Jour. 



GYNECOLOGY. 



RESECTION OF OVARIES AND TUBES. 

A. Martin gives his ( Verhandl. d. 
Deutsch. Geselhch. /. Gynakologie, 1891) 
experience of resection of ovaries and 
tubes, and expects that the operation will 
soon be recognized generally as a proper 
one. It is designed for the purpose of re- 
taining for the woman her functional 
capacity. When, on removing one ovary 
or one set of adnexa, the other is found 
only partially involved in the disease, it 
need not be wholly removed. The diseased 
part of the ovary or tube is resected, and 
the remaining part is left, an artificial 
ostium abdominale being formed in the 
case of the tube. His results of resection 
of ovaries are — 21 cases, 1 death from 
peritonitis. Of the 20 survivors, 5 have 
become pregnant, one operated on in May, 
1888, having had 3 children. He has had 
24 cases of resection of tubes, — 1 death 
from general infection of the peritoneum 
by gonococci. Of the 23 survivors 1 be- 
came pregnant, but aborted in the third 
month. 



ASCITES IN WOMEN, UNASSOCIATED 
' WITH CARDIAC, HEPATIC, OR RENAL 
DISEASE. 

G-usserow (CentralU. f. Gynak., No. 
19, 1892) opened an instructive discussion 
on this subject at a recent meeting of the 
Berlin Obstetrical Society. He for many 
years has always made an exploratory in- 
cision in these cases, being ready to take 
away any removable morbid growth that 
maybe discovered. The conditions which 
give rise to this form of ascites are, ac- 
cording to G-usserow: (1) tuberculous 
peritonitis or ' ' peritonitis nodosa " where 
no tubercle bacilli can be found; (2) pa- 



78 



Periscope. 



Vol. lxvii 



pilloma of the surf ace of the ovary; (3) 
carcinoma and sarcoma of the ovary, 
usually with similar disease of the periton- 
eum; and lastly (4) rare cases where ascites 
exists in association with small non-malig- 
nant uterine and ovarian tumors or with 
tubal disease. In all these cases there is 
absence of -oedema of the integuments and 
no signs of disease of the liver, heart, 
or kidneys. He rejects exploratory 
puncture, whether by means of a hypoder- 
mic syringe or the old trocar. Schaffer 
said that the ascitic fluid in cases of dropsy 
from inflammation or irritation of the peri- 
toneum is of a specific gravity always ex- 
ceeding 1015; whilst in cases of dropsy 
from stasis — including hepatic cirrhosis 
compressing large veins, and tumors or 
aneurisms pressing on the vena cava, dis- 
eases which may for long show no other 
symptom — the specific gravity of the fluid 
seldom exceeds 1012. Hence puncture is 
sometimes preferable to incision. The 
apparent cure of many cases of suspected 
" tuberculous peritonitis," when the ascitic 
fluid has been evacuated, suggests a non- 
tuberculous " peritonitis nodosa " imper- 
fectly recognized by pathologists. Mac- 
kenrodt believes in this distinction, and de- 
clares that he has never known a case of cure 
after incision where true tubercle of the per- 
itoneum was detected. He has frequently 
seen a diffused vesicular disease of the peri- 
toneum associated with ascites — "herpes 
peritonei." This affection was not malig- 
nant and the ascites did not return after 
incision. Ascites is sometimes caused by 
enlarged non-malignant retroperitoneal 
glands ; incision seems to cure these cases. 
Mackenrodt objects to puncture, as it may 
involve haemorrhage or damage to internal 
organs; in incision these accidents are 
rare, and when they occur cannot be over- 
looked. Winter has not entirely rejected 
puncture; it allows of bimanual explora- 
tion of the pelvic organs. Incision is not 
without danger, and hastens death in 
cases of carcinoma. G-ottschalk believes 
in a distinct peritonitis nodosa, but incis- 
ion, he stated, sometimes cures true tuber- 
culous peritonitis. Jaque related a case 
of severe haemorrhage following puncture. 
In reply, G-usserow said that a low specific 
gravity of the fluid does not necessarily 
signify that the cause of disease is not re- 
movable by operation. Puncture does not 
allow of so perfect exploration as does in- 
cision. — Brit. Med. Jour. 



PEDIATRICS. 



TREATMENT OF CHOREA. 

From a study of this important subject, 
Jumon (La Medicine Moderne, No. 9, 
1892) has formulated the following con- 
clusions: 1. In common choreas, the best 
results are obtained from the use of anti- 
pyrine and arsenic. 2. In the rheumatic 
choreas, or with rheumatic manifestations, 
antipyrine is still indicated, but to this 
drug may be associated the salicylate of so- 
dium and sulphur baths which are certainly 
useful. 3. If there should be a large 
amount of hysteric element, the bromides, 
according to Dujardin-Beaumetz and Olli- 
vier, are to be employed; 4. Finally in 
cardiac choreas, instead chloral and hydro- 
therapy both of which are dangerous, the 
iodide of potassium and especially that of 
calcium should be used, 5. In all cases 
physical exercise is to be recommended;, 
especially at the gymnasium, this being 
often of great advantage. 



TYPHOID FEVER IN CHILDREN. 

A. Moussous (Arch. Clin, de Bordeaux.. 
No. 4, 1892) states that .in a series of fifty 
consecutive cases of typhoid fever in chil- 
dren under the age of 15 years he had only 
three deaths. He fully accepts the opinion 
that the disease is less serious in childhood 
than in adult life ; there is less prostration, 
less hebetude, and seldom much diarrhoea 
or pneumonia. At the same time the fe- 
ver presents the same characters as in the 
adult, and is often high — 104° and even 
more ; the pulse rate is often also increased 
to 140, but this rapidity has not the seri- 
ous significance which it would have in 
the adult, nor are complications so often 
observed. The disease, however, is more 
severe in infants under 2 years than in 
children above that age ; this fact is called 
in evidence to support the view that one of 
the reasons of the comparative mildness of 
the disease in children is the activity of 
their digestive secretions, which tend to 
inhibit the growth of the pathogenic or- 
ganism. Another reason he finds in the 
greater functional activity of the liver and 
kidneys leading to a more perfect elimina- 
tion of the poisonous bodies produced 
within the organism during the fever. 
On this head Moussous presents some new- 
observations. Bouchard and others have 



July 9, 1892. 



Periscope. 



79 



shown that the toxicity of the urine is in- 
creased by typhoid fever, and that this 
toxicity persists for a varying period after 
defervescence, for as mnch as four or five 
weeks when the disease is treated by the 
expectant method, for still longer if anti- 
pyrin is used. With the cold bath method 
the toxicity of the urine is very high dur- 
ing the fever, but ceases quickly when 
defervescence has taken place (Roque and 
Weill) ; naphthol diminishes the produc- 
tion of the poisonous substances both dur- 
ing the fever and during convalescence. 
Moussous finds the toxicity of the urine 
in children suffering from typhoid fever is 
sometimes increased during the pyrexial 
period, sometimes at its close, but that in 
either case it becomes normal after a few 
days of freedom from fever. The elimin- 
ation of the poisonous substances, there- 
fore, in children who are treated by the 
expectant method very nearly resembles 
their elimination in adults treated by baths. 
Moussous does? not recommend resort to 
baths in the case of children, and notes 
one case in which serious syncope followed 
cold sponging. He advises the adminis- 
tration of laxatives every other day, a co- 
pious milk diet and small doses of quinine. 
— Brit. Med. Jour. 



HYGIENE. 



VACCINATION STATISTICS. 

There still are found numerous oppon- 
ents of protective vaccination and no a- 
mount of evidence seems sufficient to con- 
vince their biased minds. Yet the follow- 
ing statistics, capable of but one interpre- 
tation, may prove of interest: In Riga, a 
city of 180,000 inhabitants, there were 
some 6,500 belonging to a religious sect 
living by themselves in a certain quarter 
of the town. These people opposed the 
practice of vaccination on conscientious 
grounds. Between the years 1882 and 
1887, the average mortality from small-pox 
in the city was 108 annually. From De- 
cember, 1886, to the end of March, 1887, 
about four months, there were 155 deaths 
from this cause, owing to a slight epidemic 
during that period. Of this number 71 
occurred among the orthodox population, 
"equal to 109 per 10,000, while the deaths 
among the remaining inhabitants number- 
ed only 84, equal to 4.8 per 10,000. Down 



to the year 1887, as stated above, the 
average number of deaths annually from 
small-pox was 108. After this epidemic 
vaccination and revaccination were largely 
enforced, with the result that from 108 the 
annual number of deaths due to this dis- 
ease fell at once to 8. 



NUTRITIVE VALUE OF MILK. 

A child brought up on milk alone, and 
weighing at birth 3,200 grams, will gain in 
weight as follows: 

During the 1st three months 23.35 gr. daily 

2nd " 18.35 

3rd " 13.5 

" 4th " 8.00 " 

Making the increase of weight during 
the first year about 6 kilograms. 

During the 2nd year the increase in weight will be 
about 2 k. 000 gr. 

During the 3rd year the increase in weight will be 
about 1 k. 200 gr. 

During the 4th year the increase in weight will be 
about 1 k. 700 gr. 

Making up to 5 years, a total increase of 
12 k. 570 gr. — M. P. Cules, in Rep. de 
Phar made. 



THE TRANSMISSIBILITY OF CARCI- 
NOMA 

At a meeting of the Academie des Sci- 
ences, Duplay and Cazin {La Medecine 
Moderne, 1892, No. 8,p. 113) reported the 
results of investigations as to the inocula- 
bility of carcinoma. In a first series, com- 
prising twenty- two observations, they ino- 
culated, either subcutaneously into the 
peritoneum or into the blood, rabbits, gui- 
nea pigs, and dogs, with carcinomatous 
material obtained from man, in all in- 
stances with positive results. In a second 
series of experiments they inoculated ani- 
mals with carcinomatous material obtained 
from dogs, but without producing more 
than a local inflammatory lesion, which 
underwent absorption. Attempts to trans- 
mit carcinoma from dog to dog also failed. 



MEDICAL CHEMISTRY. 



EGrGIO. 

This is a commercial article, presuma- 
bly made from the yolks of eggs, the whites 
of which have been used for preparing egg 
albumin. An analysis recently made by 
0. S. Boyer, and reported to the Chemical 
Section of Franklin Institute, gives its 
composition by analysis as water, 53.75 to 



80 



News and Miscellany. 



Vol. lxvii 



5-6.91 per cent, ash, 9.47 to 19.25; fatty 
acids, 14.66 to 16.00. The yolk of egg 
examined by same method gives water, 
51.8 to 53.72; ash, 1.0; fatty acids, 20.0. 
The conclusion is that the ash indicates 
the presence of sodium salts to prevent 
putrefaction, the presence of a little more 
water, and a little less of fatty acids than 
the egg yolk itself. 



REAGENT FOR TANNIN. 

Bsemes (Monit. de la Pharm., 1S91, 1006) 
uses as a reagent for tannin a solution con- 
taining in 10 cc, 1 gm. sodium tungstate 
and 2 gm. sodium acetate. This yields 
with tannin in acid or alkaline solution a 
straw-colored precipitate which is insoluble 
in water. The reaction is said to be very 
sensitive. 



LITHIUM NITRIDE. 

By heating lithium in a current of nit- 
rogen gas, Ouvrard (Comptes Rendus, cxiv- 
120) has obtained a product containing 38 
to 56 per cent of nitrogen, and his analysis 
leads him to conclude that the compound 
formed may be represented by the formula 
Li 3 N, or ammonia in which the hydrogen 
is replaced by three atoms of lithium. — 
Pharm. Journ. 



ANTIPYRINE AND EUPHORINE. 

When these two bodies are triturated 
it becomes difficult to obtain a powder 
that will admit of subdivision into papers. 
To overcome this, J. Mindls in the Prag. 
Rdsch. adds a little sugar and mixes with 
a spoon or spatula. A better powder may 
be obtained by rubbing the sugar first with 
a little bicarbonate of sodium before adding 
the medicaments. Powdered licorice root 
answers even better than sugar. 



EXODYNE. 

Exodyne (Odyne, pain) marketed by 
by the Orange Chemical Co. as the great- 
est analgesic and antirheumatic, consists, 
according to F. Goldmann (Pharm. Zeit.) 
of approximately 90 per cent, acetanilid, 
5 per cent, sodium salicylate, and 5 per 
cent sodium bicarbonate. 



NEWS AND MISCELLANY. 



BOTTLING UP CHOLERA BACILLI. 

A significant commentary on the ques- 
tion of interment in city cemeteries v. 
cremation is suggested by the incidents 
connected with a proposal in the Leeds 
Corporation Bill to drive a street through 
St. Mary's Churchyard, where a great num- 
ber of cholera cases were interred, and Dr. 
Spottiswoode Cameron, in reporting 
against the proposed improvement, says: 
4 ' The whole of the district is shale and 
clay. The corpses have, therefore, been 
bottled up for these sixty years in a prac- 
tically impervious casing. I find there 
has been no epidemic in that neighborhood 
within memory of my present inspectors, 
and I find no record of any whatever. My 
own feeling about the matter is that I 
should be inclined to let well alone. Al- 
though the chances are strongly that, dur- 
ing the sixty years that are gone, the 
coma bacilli have died of inanition, there 
is a possibility that it may not be so, and 
that the opening of these graves might lead 
to disaster." The clause will be withdrawn 
and the clay-conserved bacilli left at rest. 
— Brit. Med. Jour. 



TRICHINOSIS OF THE TONGUE. 

A curious and interesting case, albeit 
somewhat difficult to understand, is record- 
ed by Dr. Oitiz of Toire. The patient 
.was a man, set. 50, a robust countryman, 
with no history of syphilis nor of tuber- 
culosis,, who came for advice with an ul- 
cerated growth of his tongue. The dis- 
ease had been in progress about a year,, 
and presented the characters of an epithe- 
lioma. Some misgivings, however, were 
expressed about the precise diagnosis, in- 
asmuch as the ulceration was not of that 
foul nature such as usually occurs in con- 
nection with malignant disease. No im- 
provement having followed the treatment 
adopted after a trial of a fortnight, it was 
decided to amputate the tongue. This 
was successfully performed, and on exam- 
ination of the organ subsequently, the 
disease was found to be trichinosis, ulcera- 
tion of the thickened tissue around the 
cysts having taking place. — Med. Press. 



Vol. I,XVII, No. 3. 
Whole No. 1846. 



JULY 16. 1892 



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CLINICAL LECTURES. 

Robert Olshacsen, M. D., Berlin, Germany. 
Eclampsia 



Prof. Chas. G. Stockton. M. D.. Buffalo, N. Y. 
Hysteria and Faecal Impaction in a Neurotic Child, 8? 



SELECTED FORMULAE 

LEADING ARTICLES. 

The Prophylaxis of Puerperal Fever, 
BOOK REVIEWS 



104 



105 
107 



A. D. Rockwell, M. D., New York. N. Y. 
Discussion on Electrical Execution 



C. E. Perkins, M. D., Sandusky, Ohio. 

Acute Rhinitis with Retention of Secretion 

D. Tod Gilliam. M. D., Columbus, Ohio. 
Ventral Hernia Resulting from Abdominal Sec- 
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D. R. Brower, M. D., Chicago, 111. 
Infantile Paralysis 



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92 



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PERISCOPE. 

Therapeutics 108 

Medicine 11 

Surgery 11 

Obstetrics 11 

Gynecology 115 

Pediatrics 117 

Hygiene 117 

Medical Chemistry 119 

NEWS AND MISCELLANY 120 





CH. MARCHAND'S 

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Send for free book of 72 pages giving articles by the following contributors : 
DR. E. R. SQUIBB, of Brooklyn, N. Y. "On the Medicinal Uses of Hydrogen Peroxide.'* 

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Ch. Marchand's Peroxide of Hydrogen (Mediema/; sold only in 4=-oz., 8-oz., 
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THE 

MEDICAL AND SURGICAL 
REPORTER. 

No. 1846. PHILADELPHIA, JULY 16, 1892. Vol. LXVII— No. 3. 



Clinical lectures. 



ECLAMPSIA. 



By DR. EOBEET OLSHAUSEN, 

BERLIN, GERMANY. 



PART III. (CONCLUSION.) 

Continued from Page 4.6. 

THE THEORY OF ECLAMPSIA. 



We now come to a consideration of the 
theory of the disease. For a long time 
there have "been two main views taken of 
this question. The one accepts the hypo- 
thesis of intoxication as a cause of the dis- 
ease, while the other view looks for this 
in a change in the brain caused by anaemia 
and oedema. 

The last named theory, which is usually 
designated as the Traube-Rosenstein theory 
has from the very first stood upon a very 
weak support, because it has been neither 
anatomically nor clinically proven, and 
also because the experimental support, 
which it received from an experiment on 
an animal by Oppler, was entirely value- 
less. This experiment was a single one, 
and so complicated, that just conclusions 
could not be gathered therefrom. The 
theory lacked in anatomical support for 
the reason that in the majority of all fatal 
cases any very great changes of the central 
nervous system are not recognized. In- 
stead of the referred to anaemia of the brain, 
on the contrary a condition of hyperaemia 
is more frequently found, and also in only 
a part of the subjects, a slight oedema of 
the brain, or more frequently of the pia- 
mater is found. This oedema of the brain 
on which the coma is said to entirely de- 
pend, must be present in every case of 
eclampsia, according to the Traube- Rosen- 



stein theory. Yet, I have seen as many as 
dozens of cases, in which even after long 
continued coma there was not the slightest 
vestige of oedema. Indeed, in the already 
mentioned case of eclampsia in which there 
were 104 attacks, the brain was so dry, 
that my colleague, who was performing the 
autopsy for me, said that one could speak of 
the presence of sclerosis with far greater 
justification than oedema. 

The theory lacks clinical support, be- 
cause it disregards the almost always 
present kidney symptoms. It only explain 
the rare exceptive cases in wh ich there is 
no albuminuria. A theory which is expect- 
ed to carry weight must above all things ex- 
plain the rule rather than the exception. 
Further, the theory renders the presence 
of labor pains an almost absolute necessity 
for the existence of the disease; for the 
contracting uterus is supposed to com- 
press the abdominal aorta, and to increase 
thus the pressure of blood in the upper 
half of the body and thus lead to cerebral 
oedema. The great frequency of prema- 
ture births, (40 per cent.) however, which 
we have shown to occur in eclampsia, is a 
patent proof of the fact that the disease 
frequently begins during pregnancy. Also 
the frequent occurrence of the disease 
among primiparae and in twin births, is 
unexplainable by means of this theory. 

The poisoning or "intoxication" theory 
has, on the contrary, indisputable advant- 
ages over the former. 

It accepts an intoxication by means of 
some excrementitial matter, which directly 
or indirectly is eliminated through the 
kidneys. 

It therefore predisposes a hindrance to 
the renal secretion, or in other words, a 
renal disease, which in fact is almost al- 
ways the case. What noxious substances, 
when retained, cause this intoxication, it 
cannot at present be said. That it is 
neither uric acid nor carbonate of ammonia 



82 



Clinical Lectures. 



Vol. lxvii 



is certain. No one at present looks upon 
this disease as an uraemia in the true sense 
of the word. Whether we are dealing with 
a collection of kreatin, kreatinin, or 
urate of soda — as Stumpf suggests or with 
acentonaemia, or finally whether we are 
dealing with still other poisonous substances 
cannot as yet be determined. The clinical 
evidence in support of this view is so 
strong that its correctness is rendered 
most probable. 

Before all, it must be determined as to 
what form of renal disease must be taken 
into consideration. Formerly in essaying 
to answer this question one's thoughts na- 
turally reverted to chronic parenchymatous 
nephritis. As a fact, this disease can 
cause eclampsia, but only the fewest cases 
of eclampsia are due to such a chronic 
renal trouble. On the other hand, one can 
also say with correctness, that where 
chronic nephritis has existed before or 
during pregnancy, eclampsia only occurs 
exceptionally (in about ^ of the cases). 
In such cases severe cedemas may often 
occur, such as anasarca, peritoneal or 
pleural dropsy. often interrupting pregnan- 
cy, and still more frequently a detachment 
causing the death of the f cetus. The mother 
also not infrequently succumbs at its sub- 
sequent birth, after a pregnancy of great 
suffering, but as has been said in such 
cases eclampsia occurs with relative 
rarity. 

Especially through the investigations of 
Leyden and his pupils, we have come to 
learn that eclampsia is usually due to quite 
another and acute renal process, in which 
the principal feature is an acute fatty de- 
generation of the renal epithelium, in the 
tubulis contortis. The further results are 
the appearance of albumin in the urine, 
usually in an extraordinary amount, and 
a most severe and acute suppression of the 
secretion of urine, which is all the more 
severe since usually both kidneys are af- 
fected. If the process occurs gradually, 
as in chronic parenchymatous nephritis, 
and especially when one-sided, compensa- 
tion is established by the action of the 
other kidney, or of the affected kidneys 
themselves. In acute disturbances, how- 
ever, such a result is difficult, the poison is 
absorbed and the patient is intoxicated. 

The rapid course of the eclampsia in 
favorable cases harmonizes well with the 
rapid course of the kidney affection in the 
same cases. No sooner has the eclampsia 



ceased than in the shortest time imaginable 
the renal troubles have also disappeared. 
In two days the amount of albumin will be 
reduced to a remarkable extent, no matter 
how large it may have been, and in four to 
eight days more all traces of it have disap- 
peared. Simultaneously the previously 
greatly depressed diuresis becomes more 
free, and consciousness again returns. 

The condition of the patient and the 
function of the kidneys, remind one for- 
cibly of the stadium asphycticum of chol- 
era, as in the latter, one may regard the 
appearances of free diuresis as a probable 
indication of ultimate recovery. 

The proof of the fact that in Leyden's 
so called ' ' kidney of pregnancy " we are 
dealing with an acute process, seems to me 
to be the most important point of the dis- 
covery. Now, all can readily understand 
the acute nature of the entire affection, 
both the eclamptic as well as the other 
symptoms. 

The next question that comes to our 
mind is the manner of the development of 
the kidney symptoms, and their nature. 
Leyden is of the opinion that the condition 
is primarily one of acute anaemia, result- 
ing in ischaemic necrosis of the renal epith- 
elia. According to my own opinion the 
anatomical findings do not seem to accord 
with this view. On the contrary, apart 
from the fatty degeneration of the epith- 
elia, the formation of cylinders in the pas- 
sages of the inner substance of the organ 
especially, infiltration of the outer sub- 
stance, and more frequently a hyperaemic 
condition, at least of the cortex, or outer 
substance of the kidney. 

And now we come to a consideration of 
a more remote question, or the serological 
moment of the disease. 

For a long time the changed pressure 
exerted upon the various organs in preg- 
nancy has been blamed for these morbid 
processes, and as a fact good causes for 
such an opinion exist. The fact that 
seventy-five or eighty per cent, of eclamp- 
tics are primiparae, and that among these, 
there are many with firm muscles, and 
therefore firm abdominal walls, and finally 
that twin-births and hydramnios are espec- 
ially frequent in cases of eclampsia (among 
our 200 cases there were sixteen twin- 
births, instead of the nominal projjortion 
of two to three) — all these facts seem to 
elucidate, and indeed to leave scarcely any 
room for doubt, but that the increased 



July 16, 1892. 



Clinical Lectures. 



83 



intra-abdominal pressure plays an impor- 
tant part in the production of the disease. 

The theory of Lohlein, Halbertsma, and 
others, to the effect that this pressure 
causes a compression of the ureters, and 
in this way checks the secretion of the 
kidneys, can assuredly not be set aside or 
disregarded. 

Years ago, Stadtfeld called attention to 
the frequency of the dilatation of the ureters 
during pregnancy and parturition, and we 
have had opportunity enough to frequently 
verify this fact on the autopsy table. 
Stadtfeld* found in sixteen parturients, 
dilatation of the ureters nine times, either of 
one or both ureters. 

In our records of the autopsies of 103 
parturients, who died from diseases other 
than eclampsia, the condition of the kid- 
neys is only referred to in seventy-five cases. 
In nine of these the ureters were not dila- 
ted, in twelve cases the ureter of one side 
was dilated (ten times the right side and 
twice the left) ; in four cases both ureters 
were dilated, but usually the right more 
than the left. The dilatation always began 
at the entrance of the small pelvis. That 
portion of the ureter lying in the lower 
or small pelvis was not dilated. Stadtfeld, 
who observed this, attributed it to a press- 
ure on the ureter by the common iliac ar- 
tery. In some instances this may be the 
case, in others it more probably is. a press- 
ure between the uterus and the bony ring 
of the pelvis. The predominence of the 
dilatation of the right ureter accords well 
with the frequency of dextro- version, and 
displacement of the uterus towards the 
right, f 

That, however, the compression of the 
ureters and the renal disturbances result- 
ing therefrom, constitute the usual, or 
even a frequent clause of eclampsia, is dis- 
proved by the post-mortem findings. Loh- 
line in his thirty-two autopsies of eclamp- 
tic subjects found the ureters only dilated 
in eight cases. We found the right ure- 
ter dilated five times, the left once, with 
simultaneous intense hydronephrosis sinis- 
tra, in thirty-seven autopsies on eclamptics. 
Once we also found a slight hydronephrosis 

*Hospital's Tidende, June 26, 1861 ; see Mon- 
atsckr. f. Geb'k'de, Vol. XX, p. 69. 

fThe fact that in 78 out of the 103 parturients, 
no notice was taken of the condition of the ure- 
ters, counts for naught, since many of these were 
admitted with peritonitis or pyaemia, often not 
until some time after the birth of the child. 



of the right side, but without dilatation of 
the corresponding ureter. 

Here I agree with Schauta, in maintain- 
ing, that one most assuredly cannot blame 
the compression of the ureters with being 
a frequent cause of eclampsia. It is in- 
deed most improbable that the compression 
of one ureter, even if continued and causing 
dilatation, would under ordinary circum- 
stances cause such a disturbance of the 
renal secretions in general as to produce 
an uraemic intoxication. On the contrary, 
we do acknowledge that this may excep- 
tionally be the case, and moreover consider 
that it was so in one of our cases. 

In the case referred to the right kidney 
was a so-called " cystic-kidney," while the 
left ureter was considerably dilated, and 
the hydronephrosis was so intense, that in 
the report of the autopsy is read that- 
' ' the left kidney consisted only of a pyra- 
mid." This peculiar and rare complica- 
tion must have occasioned a considerable 
disturbance of secretion, which might well 
have been productive of eclampsia without 
any other renal disease being present. 

I hold that this case is vastly interesting 
and important, since it proves that a severe 
disturbance of the renal functions can re- 
sult in eclampsia; independently of the 
way or means by which this disturbance, 
or rather obstruction, is brought about. 

When, therefore, the compression of 
the ureters only plays an exceptional role 
in the production of eclampsia, and the 
intra-abdominal pressure seems to be a 
matter of importance, it can be asked 
whether or not a deleterious pressure is ex- 
erted upon the renal vessels. Leyden's 
views would lead one to think of a press- 
ure upon the renal artery. I have already 
mentioned that the anatomical findings 
do not concur with this view, because of 
the frequent presence of a hyperemia 
rather than an anaemia. An isolated press- 
ure upon the artery, without affecting 
the vein, is scarcely to be thought of, 
since the two vessels lie so close to one 
another. A pressure upon the vein alone, 
or upon both vessels is more probable than 
upon the artery alone. That it is by no 
means an anatomical impossibility for the 
gravid uterus to exert a pressure upon the 
renal hilus, any one will acknowledge who 
has, either at autopsies or at laparotomies, 
noticed how the posterior walls of the soft 
uterus is flattened against the spinal 
column and other organs, in such manner 



84 



Clinical Lectures. 



Vol. lxvii 



as to seem spread out against the posterior 
abdominal wall. 

The theory has been also advanced that 
the renal affections are only secondary, 
and occur after an infection or intoxica- 
tion through some other channel. Ac- 
cording to this view, the kidneys become 
aff ected and diseased, similarly as in scarlet 
fever, diphtheria and other diseases, in 
that the products of infection are elimin- 
ated through these organs, which cannot 
occur without occasioning a disturbance 
of the tissue and functions of the organs 
in question. 

The attempts, which have been made by 
Doleris and others to demonstrate the in- 
fectious origin of eclampsia must be re- 
garded as complete failures ; and there is 
no probability of any explanation of the 
aetiology of the disease coming from this 
direction. 

Then it has been endeavored to reconcile 
the theory of the products of tissue 
change (stoffwechsel) in the foetus, which 
are absorbed into the maternal circulation, 
and thus causes eclampsia. This theory 
was supported by fact that in cases of 
eclampsia in which the course of pregnancy 
has not been interrupted; with the death 
of the foetus the danger of a return of the 
eclampsia at its subsequent birth, is re- 
moved. This seems right enough, but it 
seems to me, besides the above, that in 
every case of eclampsia of pregnancy which 
has been checked without occasioning the 
birth of the foetus, the disease will fail to 
return at the time of delivery, whether the 
child is dead or alive. I have seen two 
such cases (not included in the two hun- 
dred cases upon which this article is based), 
in which the pregnancy proceeded after the 
cessation of the eclampsia, and ended 
finally in the birth of a living child. 

The one case was that of a duopara, 
twenty-eight years old, who had four 
eclamptic convulsions, and five days later, 
a fifth convulsion, and after the lapse of 
ten days more, was delivered of a living, 
although perhaps premature child, weigh- 
ing 1760 grammes and 44 centimetres in 
length. The second case was that of a 
primipara who had thirteen convulsions. 
These ceased after the hypodermic exhibi- 
tion of 0.05 gram, morphine, and the 
patient's consciousness fully returned. 
Twenty-four hours later labor began, and 
thirty-four hours after the last attack she 
delivered a living child. 



C. Braun, also, in his work,* saw a liv- 
ing child born fourteen days after the ces- 
sation of eclampsia, and after the albumin- 
uria had also disappeared. 

In the yearly report of the Obstetrical 
Department of the Charite Hospital (Ber- 
lin) for 1888-89, there are four cases re- 
ported by Hensoldt, of eclampsia of preg- 
nancy, in two of which living children were 
born three and seven days after the dis- 
continuance of the eclamptic attacks, and 
without causing their removal. 

Brummerstadtf has also reported that 
in thirteen cases of eclampsia occurring 
during pregnancy, between six hours and 
twenty- one days later, six dead and seven 
living children were born ; and only in one 
case did the convulsions, which had ceased 
for six days, return. 

Also the fact already referred to, that 
eclampsia not infrequently occurs long 
after the death of the foetus, only tends 
further to prove the incorrectness of the 
theory in question. 

So long as it has not been proven, that 
the death or life of the foetus makes the 
least difference, the theory that eclampsia 
is due to an intoxication emanating from 
some foetal secretion, has not the least 
weight. 

I will now turn to a theory recently ad- 
vanced by HerffJ regarding the theory of 
eclampsia. According to this auther 
eclampsia is due to a peculiar excitability 
of the psychomotoric centres of the brain 
— for instance the subcortical centres. 
This excitability develops during preg- 
nancy through the basis of an inherent 
psychopathic condition; yet that the 
physiological irritation produced by ges- 
tation does not usually suffice to cause the 
disease, but is augmented by other excit- 
ing causes, notably a slight uratin intox- 
ication. 

This explanation of the disease, so far 
as the psychological condition is concerned > 
seems to us to be an entirely unproven one,, 
although it may seem justifiable to the 
views of modern neuro-pathologists who 
always look for some hereditary or neuro- 
pathological cause. Otherwise the theory, 
seems to contain only a round-about 
description of the facts of the case. 

Among the means, which are at the 

*C. Braun, Lehrbuch d. gebh. 1857, page 489. 
fLoc. cit., p. 100. 

\Miinchener med . Wochenschrift, 1891, No. 5. 



July 16, 1892. 



Clinical Lectures. 



85 



service of investigators to enable tliem 
to clear away what is obscure regarding 
the disease, those made use of by Fehling 
and Stumpf , which deal with an examina- 
tion of the secretions and blood, seem to 
us most justifiable. The experiments upon 
animals which have been undertaken in the 
endeavor to produce an artificial eclampsia 
have so far revealed nothing ; and if they 
ever expect to, they must surely be un- 
dertaken in some different manner. 

At this point, I would take the op- 
portunity to say, that there is an intoxica- 
tion, which is capable of producing con- 
vulsions, such as no experiments upon 
animals have equalled, and which resemble 
eclampsia convulsions to the most minute 
point. I refer to the intoxication, or 
poisoning producible by bichloride of 
mercury. The convulsions caused occa- 
sionally by this drug, are in every respect 
exactly like those of true eclampsia. They 
occur after short intervals, and may be 
easily mistaken for eclamptic convulsions. 

This deception, as a fact, occurred in 
a case of ours. The patient was a septa- 
para, in whom on account of a narrow 
pelvis, an abortion was contemplated, and 
with this end in view a bichloride solution 
(1 to 15,000) was injected between the 
foetal membranes and the wall of the uterus. 
She was shortly after delivered of a dead 
child without assistance and eight days 
later had two eclamptic attacks. The 
temperature of the patient went up to 
40. 30° 0., and the pulse 116. The attack 
was considered to be eclamptic, and it was 
only the autopsy that revealed the truth. 
Besides the nephritis, there was diphthe- 
ritis of the large intestine, especially intense 
in the ascending colon. Both kidneys were 
enormously enlarged or, at a later exami- 
nation (not undertaken by us) were found 
to be affected with necrosis of the epithelia, 
with a deposit of phosphate of lime in the 
passages of the organ. 

The very late appearance of the eclamp- 
sia, at the eighth day of the puerperium, 
proves the correctness of this aetiology. 

We can draw an instructive lesson from 
this case; namely, that in puerperal eclamp- 
sias which occur very late, the possibility 
of a bichloride of mercury poisoning (pre- 
supposing that the drug has been used) 
must be considered. In an exactly similar 
way, I observed eclamptic attacks in an 
old woman, which were not but a symptom 
of bichloride of mercury poisoning. One 



case, similar to ours, has been reported by 
Lohlein* The patient was a primipara, 
thirty-eight, who during the child-birth, 
had received several uterine injections of 
carbolic acid solution. Afterwards the acid 
appeared in the urine, and fifteen days after 
the birth of the child, the patient had five 
eclamptic attacks. The patient recovered. 

It cannot be denied, however, that rarely 
cases of true puerperal eclampsia occur 
some time after delivery. In 1869 I saw 
such a case. The first attack occurred 
fifteen days post-partum, and the patient 
died after the fourth convulsion. The 
urine contained neither albumin nor cyl- 
inders. In the report of the autopsy, both 
kidneys were described as being in the 
" second stage of Bright's disease." f A 
lew other cases have been reported by 
Lohlein. | 

Between this kind of toxic eclamptic 
convulsions and eclampsia gravidarum 
there is a decided analogy, which consists 
in a more or less acute obstruction of the 
secretion of urine, and it can also occur 
that both will have the same effect and 
cause the same pathological process. So, 
it can be very possible that in searching 
for the cause of the convulsions in bichlo- 
ride of mercury poisoning, we may be able 
to throw additional light upon the cause 
of the true eclamptic convulsions. In 
order to tersely express my own theory 
as to the aetiology of eclampsia gravida- 
rum et parturientium, I will briefly repeat 
what I have said at length in this article : 

The disease consists in an intoxication, 
caused by what as a rule consists in a 
rather acute obstruction to the functions 
of the kidneys. The latter consists in the 
majority of cases in an acute or subacute 
pathological change in the parenchyma of 
the kidney, and especially also of the epith- 
elium of the passages in the kidney. More 
rarely chronic parenchymatous nephritis 
(morbus Brightii), or interstitial nephritis 
can be the cause of the disturbed renal 
secretion; or, it may go as far as a chronic 
interstitial nephritis, and an acute fatty 
degeneration, in which case a deleterious 
result can be occasioned with greater ease. 
Exceptionally, entirely different changes 
in the kidneys can give rise to an acute 
suppression of the secretion of urine ; f or 

*Zeitsc?ir. f. Gebh., Vol. VIII., p. 537. 
f See Mave, Dissertation, Halle, 1869. 
X Lohlein, loc. cit. 



86 



Clinical Lectures. 



Vol. lxvii 



instance, in especially favorable cases (such 
as previously impaired function of one 
kidney), acute suppression of the secretion 
of urine by compression of the ureter, and 
hydronephrosis or a pathological change 
of the renal parenchyma by toxic sub- 
stances (bichloride of mercury or carbolic 
acid). These last add by far greater weight 
to the theory of intoxication. 

If an attack of eclampsia ceased with- 
out interrupting the course of pregnancy, 
then at the birth which occurs later there 
is scarcely ever a repetition of the disease. 
That this is due to the death of the foetus 
has not been proved. 

For the prognosis of eclampsia the possi- 
bility of quickly terminating the delivery 
must be taken into consideration, as well 
as the number of convulsions and their in- 
tensity. A high temperature and a bad 
pulse indicate the worst possible prognosis. 

The sensu strictori puerperal eclamp- 
sias seem to offer a favorable prognosis, if 
they occur within one or two hours after 
delivery. If they occur some time after 
delivery they offer a most unfavorable prog- 
nosis. 

Numerous cases of eclampsia (3.0 to '40 
per cent.) occur before any appearance of 
labor, during the course of pregnancy. 

In a very few cases there is a warning 
or aura before the first eclamptic attack, 
or else it seems that the consciousness of 
the patient is retained during the first part 
of the convulsion. 

The absence of albuminuria is a most 
rare occurrence, and also the absence of 
pathological changes of the kidneys (found 
at the autopsies) is very rare. 

Regarding the therapy, I recommend 
morphine in large doses and when on ac- 
count of the small pulse and greatly con- 
tracted pupils, no more may be given ; then 
chloral by rectal injection. 

In multipara? the amniotic sac should 
be ruptured as soon as possible in order to 
induce, and accelerate the birth of the 
foetus. So soon as the size of cervix no 
longer offers any opposition, the forceps 
should be resorted to. Version and in- 
cision of the cervix, is a practice that 
should be restricted as far as possible. 

In exceptional cases, for the sake of the 
mother, or if she is moribund, for the 
sake of the child, Cesarean section is in- 
dicated ; but it is never quite impossible 
to give any precise indications as to when 
it is justifiable. 



translator's conclusion. 
In presenting this most exhaustive and 
admirable article on Eclampsia the trans- 
lator feels convinced that the Reporter, 
has made a valuable addition to the litera- 
ture on this subject in the English lan- 
guage. 

In translating, very little change from 
the original has been made, other than 
frequent amplification for the sake of 
clearness and a weeding out, as far as 
possible, of abstruse scientific terms, with 
which the original abounds, and then sub- 
stitution of plain English. The writer's 
facile style has been reproduced as closely 
as possible. The quotations from other 
works have been verified as far as possible. 

The following literature has been made » 
use of in this work : 

Lohlein, Zeitschrift filr Geburtshillfe 
und Gynakologie. 

Lohlein, Gynakologische Tagesfragen. 

Schauta, Archiv fur Gynakologie, 
Vol. XVIII. 

Brummerstadt, Report of the Rostock 
Midivives- school , 1865. 

BRAUN,CHiARi,cmd Sp&th, Obstetrics. 

Winckel, Handbook of Obstetrics, 1889. 

Dohrn, Zur Kentniss der Eklampie, 
tubilla Programme, Marburg, 1867. 

Hugenbergek, Report of the St. 
Petersburg (Russia) School for Midivives. 
. Hofmeier, Zeitschrift fur Geburtshillfe, 
Vol III. 

Meye, Dissertation at Halle, 1869. 

Lohlein, Zeitschrift filr Geburtshillfe, 
Vol. VIII. 

~HLERFF,Munchener med. Wochenschrift, 
1891, No. 5. 

Stadtfeld, Monatschrift filr Geburts- 
kunde, Vol. XX. 



ON A GENERAL INFECTIOUS COMPLI- 
CATION IN LUPUS VULGARIS. 

V. Lespinne (Le Merer edi Medical, 
1891, No. 35) believes that there may be 
produced in the course of the evolution of 
lupus a special general complication due 
to absorption of toxic microbes taking 
place from the surface of the ulcer, this 
poisoning announcing itself by a sharp in- 
crease of temperature, with typhoidal state, 
catarrhal phenomena of the mucous mem- 
branes. This complication may be the 
signal for the period of invasion of the 
whole organism, general tuberculosis tak- 
ing the place of the local tuberculosis of 
the skin. 



July 16, 1892. Clinical Lectures. 87 



HYSTERIA AND F.ECAL IMPAC- 
TION IN A NEUROTIC CHILD. 



By PROF. CHAS. G. STOCKTON, 

MEDICAL CLINIC, BUFFALO GENERAL 
HOSPITAL. 



This little patient I have not seen be- 
fore but I understand that the case is one 
of faecal impaction. The history is as 
follows: H. S., aged 12, born in N. J., 
entered Hospital Sept. 29; parents, two 
brothers and two sisters living and well, 
none dead. The boy says that when a 
baby three weeks he was sick but his 
parents have never told him what the 
trouble was. From this time the abdo- 
men began to increase in size. There is 
no history of traumatism. The patient 
can remember that the abdomen was con- 
siderably distended when he was four or 
five, and the bowels were very irregular, 
passage occurring at intervals of from 
three days to two weeks, and then un- 
usually, because pills had been taken. 
After free movement of the bowels, the 
abdomen has diminished in size. No pass- 
age for three or four weeks till the day 
previous to entering hospital. 

It is a good plan always to examine a 
patient carefully in a general way before 
beginning the special examination, of the 
region supposed to be affected. The 
patient is a bright looking boy, though 
rather neurotic apparently. On raising 
his hand and arm, he holds the limb ele- 
vated for two or three minutes without 
moving. He lies unnaturally quiet for a 
child of his age, suggesting the state of 
trance. There is a peculiar tremor of the 
eye lids which is quite characteristic of 
hysteria. Children, even males, we must 
remember, are apt to be hysterical as well 
as women. The tongue is coated, rather 
broad and somewhat indented by the 
teeth. The gums appear fairly healthy 
and neither here or else-where is there 
evidence of anaemia. The breath is ex- 
ceedingly unpleasant. The boy says his 
appetite is usually good though he ate no 
breakfast this morning. 

The chest is cone-shaped as it usually 
is in young children who have punchy ab- 
domens from accumulation of gas or 
faecal matter, or from any enlargement of 
the viscera which causes encroachment on 
the thorax and stretching out of the lower 
ribs. If this child should maintain the 



stretching of his lower ribs until they have 
hardened from the deposition of lime 
salts, the chest would remain permanently 
in this shape. The crooked and variously 
distended chests which you so commonly 
see, date back in most cases to infancy 
and are due to abdominal distention or 
chronic cough, the result of bronchitis, 
emphysema, etc., particularly when 
rachitis is present. 

Such an enormous abdomen might be 
due to distention of the stomach or intes- 
tine, to enlargement of the liver or spleen, 
or ascites. The liver is, of course, pressed 
upward, even if not enlarged, and we find 
on percussion that dullness begins just 
under the nipple. The area of dullness is 
not extensive, reaching barely to the edge 
of the ribs, but even there there is reson- 
ance due to the condition of the intestine. 
There is no indication of enlargement of 
the spleen, by percussion. The abdomen 
is tympanitic. So there cannot be ascites. 
The trouble is due to the distention of the 
intestines or stomach, or both. 

Why should faecal matter accumulate in 
the intestine of a child of this age? The 
causes of faecal obstruction are usually to 
be studied in connection with the causes 
of chronic constipation. Chronic consti- 
pation in children must be due either to 
lack of innervation, and therefore loss of 
motility on the part of the muscular coat 
of the bowel, or to a lack of secretion, 
both of which elements facilitate the evac- 
uation of the bowel. At the caecum there 
is a certain obstruction to the current of 
faecal matter in the small intestine, and 
normally the consistency now increases 
gradually till it reaches the sigmoid flex- 
ure, which is a sort of valve, where the 
faecal matter is held until the act of defeca- 
tion. Sometimes, however, it is retained 
in the rectum, but normally above the sig- 
moid. Anything that will for a long time 
lead to imperfect secretion or imperfect 
motility of the bowels, will also cause con- 
stipation. The trouble more often occurs 
in the large intestine than in the small, 
and more often in the sigmoid region than 
in the rectum. Weakening of the motility 
of the intestine is a kind of paresis, and it 
may, in an extreme degree, almost amount 
to a paralysis. This lack of motility is apt 
to come about through negligence of tne 
bowels ; a person who does not respond to 
the demand of the bowels for evacuation, 
blunts the sensibility of the part and leads 



88 



Clinical Lectures. 



Vol. lxvii 



to its sluggishness, and this is the most 
common way in which chronic constipa- 
tion is acquired. Those who are disturbed 
in intellect and blunted in their sensibili- 
ties generally, are almost always affected 
with sluggishness of the bowels. The neu- 
rotic comes into this class and here we 
must place this boy. Again, the muscu- 
lar coats of the intestine may be weakened 
from inflammation, the mucous membrane 
secreting less abundantly, and therefore 
furnishing less lubricating matter for the 
movement of the intestinal contents. In- 
flammation of the serous covering of the 
intestine — that is peritonitis — also causes 
weakening of the muscular power of the 
bowels. In chronic enteritis, the normal 
secretions are changed, mucus may be 
secreted in considerable quantities, but at 
other times, even that secretion is scanty. 
We therefore have diarrhoea followed by 
constipation, and again diarrhoea. With 
these cases of chronic catarrh we often find 
the accumulation of large scybalous masses 
which cannot be expelled, although around 
them the thinner faecal matter passes and 
there are evacuations of the bowels while 
the hard masses remain in place. Some- 
times these scybalae become so hard that it 
is difficult to indent them except with a 
sharp instrument. This condition is rare 
in the small intestine, happening most 
frequently in the transverse colon and sig- 
moid flexure, but also in the caecum and 
the rectum. Persons thus affected may 
say that there is a regular movement of 
the bowels every two or three days, and on 
examination we may find the rectum filled 
with a hard mass, which no power of the 
the patient can expel, but the irritation 
may set up an increase of the secretion 
around it, and thus there will be periodi- 
cal diarrhoea. This mass should be dug 
out with a spoon-handle, the spatula, or 
whatever happens to be at hand, and it 
may be softened with an emetic of warm 
water, assisted, it may be, by oxgall or 
Epsom salts. 

In this case, on account of the neurotic 
element, the child has neglected to empty 
the bowels and a lack of motility has 
been developed. From the retained faecal 
matter, gas is evolved which he belches up 
through the mouth. The foul breath and 
the coated tongue are very natural accom- 
paniments. One would suppose that there 
would be sufficient toxaemia from the long 
retention of faecal matter to make the boy 



sick but his general condition seems good 
and he has no fever. I should advise giv- 
ing him in the first place calomel to stim- 
ulate the secretion of the bowel, with it 
might be given small quantities of ipecac. 
I should then give him castor-oil in regu- 
lar doses, perhaps half an ounce every two 
hours repeated till the bowels are empty. 
Meanwhile the bowels should be cleaned 
out from below, by the finger and spoon if 
necessary, in order to empty the rectum, 
and following this an enema and then a 
soft tube should be introduced 24 to 30 
inches and a solution of ox-gall 5ij- to a 
quart of water should be carried high into 
the colon. This is usually the most effi- 
cient means of softening such a hard faecal 
mass. 

Note. — Ten days later the boy was 
presented at the clinic, when he was ap- 
parently well. This change resulted from 
the treatment described to you, with the 
addition of half a pint of the milk of asa- 
foetida, in divided doses daily. 

Further observation showed that the 
boy was in the highest degree hysterical 
and, undoubtedly, for his improvement we 
are largely indebted to the asafoetida. 



A NEW VARIETY OF TROPHO NEUROSIS 
OF THE SKIN. 

Mm. Hollopeau and Larat {La 'Semaine 
Medicale, 1891, No. 47) describes a condi- 
tion of the skin characterized by dyschro- 
mia and lichenoid eruption. Reference is 
made to the various dyschromias due to 
nervous origin which have been described 
by authors, and to the concomitant phe- 
nomena, consisting of disturbances of sen- 
sibility and of the vascular system, and 
disorders of secretion; to which may be 
added, as shown by a case of the author's, 
impaired nutrition of the hairs. A case 
recently observed shows that lichenoid 
papules may also be produced by the same 
causes. They make a resume of their ob- 
servations as follows: There exists a der- 
matosis characterized by achromatous 
patches surrounded by a papular border 
and by increased pigmentation. This der- 
matosis is probably a cutaneous manifesta- 
tion or hysteria. The papules, lichenoid 
in kind, may be of a tropho-neurotic origin. 
They are not necessarily akin to pruritus. 
Cutaneous electrization in the form of 
bath, with the faradic current, seems to be 
indicated. 



July 16, 1892. 



Communications. 



89 



Communications, 



DISCUSSION OX ELECTRICAL 
EXECUTION.* 



By A. D. ROCKWELL, M. D. 

NEW YORK. 



While I do not believe that the best 
use to which a man can be put is to kill 
him, yet all will agree that if the law will 
kill, let it kill decently. It is evident 
that the sentiment against hanging and in 
favor of some method quicker and less re- 
pulsive is strengthening and that other 
methods will sooner or later replace the 
rope everywhere. Mr. Edison while in 
Paris during the exposition gave his opin- 
ion so positively in regard to the efficiency 
of electricity that the Medical section 
of the French Academy of Sciences aided 
by Marcel Duprez, a prominent electrician, 
have had the matter under careful investi- 
gation. There is always opposition and 
friction attending changes for the better, 
and this change has been no exception to 
the general rule. The whole tendency of 
our civilization is however in the direction 
of humane methods in dealing with crimi- 
nals and that form of execution which is 
quickest and least repulsive should be 
adopted. It is a mathematical ' impossi- 
bility that any human being receiving in 
proper form an electrical current of lethal 
energy should appreciate even for a frac- 
tion of a second the slightest pain. It has 
been ascertained that the brain is one- 
twenty-fifth of a second in recognizing an 
impression, and one-twenty-eighth of a 
second in telegraphing that an impression 
has been received, and as nerve force travels 
only about 100 feet a second, while the 
velocity of the electric current is millions 
of times greater than this, the brain has 
absolutely no time to appreciate a sense of 
pain. As between electricity and certain 
other methods of capital punishment it is 
not altogether clear that the former is the 
best that could be suggested. The 
guillotine and the garote are practically 
instantaneous and painless in their action 
and attended with only a fraction of the 
paraphernalia and expense of the method 
now adopted in Xew York State. There 

* Read before the Neurological Section of the 
American Medical Association, Detroit. June 8, 
1892. 



is however an apparent brutality attend- 
ing both these methods that repels, and a 
mutilation and shedding of blood, which 
public opinion in this country seems un- 
willing to tolerate. 

The action of poison is open to none of 
these objections, arid it seems somewhat 
singular that it has not more strongly com- 
mended itself to the philanthropic mind 
seeking simpler and more humane methods 
in the legal taking of human life. But as 
between electricity and the rope there can, 
it seems to me, be no question. Let us 
suppose that it had been customary to exe- 
cute by electricity instead of by hanging, 
and that some one in the supposed inter- 
ests of humanity should suggest that the 
former method be abolished, and the lat- 
ter substituted ; that a method practically 
instantaneous and painless, unattended by 
mutilation and without any distressing 
outward manifestations of pain, be re- 
placed by one which usually fails to ex- 
tinguish life for ten or twelve miuutes, 
which in many cases it is reasonable to be- 
lieve is attended with torture, and where 
the convulsive manifestations are horrible 
to witness — such a suggestion could not 
have the slightest claim for serious con- 
sideration, and as a matter of fact would 
never be offered. 

After the passage by the legislature of 
the state of Xew York of the law substi- 
tuting electricity for hanging in the execu- 
tion of criminals, there arose a terrible 
storm of opposition that apparently had for 
its basis extensive commercial interests. It 
was claimed by the opponents of the new 
method, that electricity was by no means 
certain to destroy life without the infliction 
of great pain, and the popular mind was 
agitated by repeated assertions of the pos- 
sibility and probability of repulsive dis- 
figurement by the heat and chemical action 
that would necessarily be developed in the 
use of currents of such great power. To 
determine these points and to advise the 
state as to the best methods of procedure, 
a commission was appointed consisting of 
Dr. Carlos MacDonald, Chairman of the 
State Commission in Lunacy, Prof. L. H. 
Lady, of Columbia College, and the writer, 
who both at the Edison Laboratory and at 
the various prisons of the state, experi- 
mented largely upon animals, and tested 
many devices and methods for the applica- 
tion of the current. There could be no 
charge of cruelty in these investigations 



90 



Communications. 



Vol. lxvii 



for in no single instance was there any 
evidence that the slightest pain was in- 
flicted. 

The largest animals such as horses and 
a bull instantly succumbed to an electric 
pressure of one thousand volts, while dogs 
and calves were as readily destroyed by 
five and six hundred volts. 

But one impact of the current was found 
necessary, for death was instantaneous in 
every case. 

Immediate examination after the open- 
ing of the circuit invariably failed to elicit 
the slightest respiration or heart beat, and 
careful and persistent efforts at artificial 
respiration conducted by Dr. Fell, of 
Buffalo, with the latest and most approved 
appliances were without avail. 

In view of the fact thus satisfactorily 
demonstrated that one thousand or at the 
most fifteen hundred volts would instantly 
kill any animal large or small, we very 
naturally inferred that any human being 
would succumb even more readily, but to 
make assurance doubly sure, it was recom- 
mended that not less than 1,500 or 2,000 
volts be employed in the execution of crim- 
inals. To our great surprise therefore it 
was demonstrated at the first electrical exe- 
cution and confirmed in every subsequent 
attempt, that it was far more difficult to 
kill a man by electricity than any ordinary 
domestic animal however large. In the 
only execution which the writer attended, 
when four criminals were successively sub- 
jected to the electric stroke, the first con- 
tact of twenty seconds with a voltage of 
1,700 left its victim apparently lifeless, 
with the exception of a slight fluttering of 
the pulse and what appeared to be a slight 
expiratory effort. 

Because of these faint evidences of vital- 
ity it was decided then and has been cus- 
tomary since to repeat the shock once and 
sometimes twice. That the victims were 
however in every instance so thoroughly 
devitalized by the first shock as to pre- 
clude the possibility of resuscitation, and 
that every vestige of consciousness was in- 
stantly obliterated, admitted of not a 
shadow of a doubt. In these cases a man's 
brain acts in two ways and I should say 
that the reasons for this increased strength 
of current necessary in the case of a human 
being were both physical and psychical. 
In the first place, the man knows' what is 
coming and every nerve and muscle is tense 
with involuntary resistance. There is a 



mysterious likeness between nervous force 
and electric force; not a resemblance ex- 
actly, but a something about each which 
science has yet to fathom. 

I have no doubt that this nervous ten- 
sion operates directly to impede the action 
of the electricity, while the secondary ef- 
fect is physical. The body conducts elec- 
tricity by virtue of its saline solutions. 

Now, fright drives the blood away from 
the surface to the central portions of the 
body. 

When a man is placed in the chair he is 
necessarily terribly frightened, and the re- 
sult is that the surface tissues are un- 
naturally dry, and hence inferior conduc- 
tors. With an animal these influences do 
not prevail, but the most striking confir- 
mation of the probable truth of this sug- 
gestion lies in the fact of the greater 
readiness with which life is extinguished 
in men from accidental contact with elec- 
trical energy. 

Even where the contact has been in- 
complete and imperfect, linemen have been 
instantly killed with electrical potentials 
no greater than those employed in judicial 
executions. When a man thus accidentally 
comes in contact with the current, his will 
or nervous force is in a passive state and 
offers no resistance to the action of the 
current, while the surface of the body is 
usually flushed with the exertion of work 
and in the highest state of conductivity. 
Notwithstanding the efforts of a united 
press to exaggerate results, no one who 
has once witnessed a properly conducted 
execution by electricity can fail to com- 
mend it as a most humane method as com- 
pared to hanging. Aside from the fact 
that a human life is being taken by 
violence, there is little in connection 
with the execution that is revolting to 
the senses. After the first convulsive 
movement as the current is received, 
every muscle is simply tense and motion- 
less until the current is broken when relax- 
ation takes place and the man is to all 
intents dead. 

It will be recollected that the press 
raised a great outcry against the use of 
electricity, not only because of its sup- 
posed inefficiency, but because of what 
was described as repulsive mutilation by 
burns and scalds. While the degree of 
heat generated and the influence exerted 
upon the superficial tissues, varied in the 
different cases, according to the position 



July 16, 1892. 



Communications. 



91 



of the electrodes and the density of the 
current near the points of contact, in no 
instance was there any snch repulsive 
disfigurement as has been intimated, and 
in all but one or two the effects produc- 
ed were so superficial and slight as to be 
unworthy of comment. It cannot be 
denied however, that owing to the limited 
area through which the tremendous voltage 
required has to operate, and the immense 
resistance offered to its passage there oc- 
curs a remarkable drop in potential and 
an astonishing development of heat, which, 
without the exercise of the most intel- 
ligent and careful supervision, might re- 
sult in such severe burning as to bring 
under public condemnation a method which 
thus far commended itself to all eye-wit- 
nesses. 

But it is not voltage alone that kills, but 
its rate of expenditure in the body as ex- 
pressed by amperes, and the time consumed 
in its expenditure as expressed by the volt, 
ampere seconds indicating the measure of 
the heat developed during the action of the 
current. As stated by the distinguished 
electrical expert, W. J. Jenks: "None of 
these factors are well settled as yet in their 
relation to the energy actually required to 
cause instant and painless death. By 
death, I mean now not alone cessation of 
consciousness of a perfectly healthy human 
being in an interval too brief for thought 
to measure, and the establishment of con- 
ditions which produce gradual and final 
expenditure of the stored nervous energy 
of the brain and the subordinate centres 
of distribution of vital force — such as the 
pneumogastric nerve and the spinal cord — 
I mean also, total paralysis of all the vital 
organs and of the nervous centres by which 
they are directly or indirectly vitalized, 
and by which the muscles of the extremi- 
ties are actuated, so that when the current 
is broken there can be no reflex action of 
the muscles, such as would indicate the 
presence of residual life energy, or a pos- 
sibility of its resuscitation/' 

The question which physicists must de- 
termine is how with a comparatively low 
voltage the same number of amperes that 
are expended upon the periphery and 
therefore in a measure lost — could be made 
to act exclusively on the centres of life and 
nervous activity, instantly devitalizing 
them while leaving no outward manifesta- 
tions of the terrific power employed. It 
has been asserted that the subject of exe- 



cutions by electricity is one with which 
the physician should have nothing to do, 
and vigorous protests have been made 
against the propriety of allowing the 
subject of legal executions to be discussed 
in our medical societies. 

In arguing that the function of the phy- 
sician is to save life and not to be in any 
way connected with devices that destroy, 
it is forgotten that in one of the depart- 
ments of our art, our noblest efforts are en- 
listed in taking, for the purpose of saving 
life ; and when death is inevitable the phy- 
sician is at hand to soften the transition 
from visible time to invisible eternity. 
When the law therefore decides that some 
new and better method be adopted in the 
disposition of those against whom its 
heaviest penalty has been decreed, who 
but he should be selected to advise the 
state as to the proper technical methods of 
procedure. 

Whatever is worthy in action, is proper 
in discussion and as one of the advisory 
commission appointed by my state in the 
interests of the best methods of execution 
by electricity, I have felt that our work 
was never along more truly professional 
lines or more in the interests of humanity. 



THE TREATMENT OF HAEMORRHOIDS. 

At a meeting of the Medical Society of 
London, Lauder Brunton (Lancet, No. - 
3576, p. 583) dwelt upon the influence of 
cold and over- eating in the development 
of haemorrhoids. Mercurials, followed by 
mild salines, are useful in preventing hep- 
atic congestion. Aloes, in large closes, 
may conduce to the development of haem- 
orrhoids by over-stimulation of the muscu- 
lar coats of the rectum. Small doses, on 
the contrary, exert a beneficial influence. 
Hepatic congestion due to cold may be 
relieved by the application of hot- water 
bags to the nape of the neck and over the 
liver. Patients subject to haemorrhoids 
should become accustomed to emptying 
the bowels at night, so as to secure rest 
in the recumbent posture. When there 
is much irritability at the anus it is prefer- 
able to use a soft sponge and water instead 
of paper more or less harsh. A pledget 
of animal wool dipped in hamamelis and 
introduced into the rectum will act as a 
mechanical support and as an astringent. 
In obstinate cases an anal pad may afford 
great relief. 



92 



Communications. 



Vol. lxvii 



ACUTE RHINITIS WITH RETEN- 
TION OF SECRETION.* 



By C. E. PERKINS, M. D., 

SANDUSKY, OHIO. 



Iii taking up a small portion of your 
time, to-day, I desire to call your attention 
to a case which has been very interesting 
as well as somewhat perplexing to me, 
and I hope that the narration of this case 
may bring to your minds similar ones 
which you have met in your experience. 
And if it does, I would like to ask you to 
narrate them for our mutual profit, as in 
trying to find some elucidation of this sub- 
ject, in text books and articles in medical 
journals, I have been greatly disappointed. 
We know that but very few cases, com- 
paratively speaking, of acute catarrhal 
rhinitis are accompanied with symptoms 
of sufficiently severe character to lead 
the patient to consult a physician, but 
that these do occur in which the diagnosis 
is very difficult and the symptoms severe, 
I think will be shown from the following 
case: 

Miss M. K., aged 30, unmarried, con- 
sulted me on Feb. 9th, this year; her 
family, as well as personal history, was 
negative as to tubercular, rheumatic and 
specific disease; unless we might be in- 
clined to consider an attack of measles (so 
called) occurring in January, '91 as a syphil- 
itic manifestation ; but I cannot do so as 
some four or five other members of the 
'family had the same trouble at the same 
time and all recovered without treatment 
of any kind. Up to the commencement 
of this trouble she had been exceptionally 
healthy and robust, having never required 
the services of a physician. 

In the latter part of October last she 
was taken with what she considered an 
ordinary cold. There were the ordinary 
symptoms of acute catarrhal rhinitis, 
viz : malaise, dryness and heat of the nose 
followed by discharge, etc., etc., but she 
had in addition to all these a severe neural- 
gia on the right side of the face, which 
persisted for about a month. Early in 
December complete stenosis of 'the right 
side of the nose developed and the left was 
partially occluded. At this time there 
was a swelling across the nose, frontal and 

*Read before Ohio State Medical Society at 
Cincinnati, May 6th, 1892. 



nasal pains, and slight epiphora, and there 
was very little running from the nose and 
that of a watery character. About these 
same symptoms continued until just be- 
fore Christmas when she consulted her 
physician. I am quite certain that he con- 
sidered the case as one of nasal syphilis, 
for he prescribed mercurial inunctions and 
insufflated iodoform daily. She continued 
under his care for six weeks. At one time 
in January she had a hoarseness for one 
week. The right nostril continued oc- 
cluded and the left became completely so, 
although he was adopting rigorous anti- 
syphilitic treatment. Not making any 
improvement she consulted me on the 9th 
of February. I found her weak and anae- 
mic and somewhat emaciated. There was 
complete loss of appetite, and swelling, 
redness, and pains across the nose. 

These pains were so severe as to inter- 
fere with sleep; there was complete steno- 
sis of both nasal passages which caused 
the characteristic voice of nasal occlusion. 
This, upon inspection, appeared to be due 
to thickening and infiltration of the tur- 
binated bodies and septum; they were in 
contact about one fourth of an inch from 
the anterior nares. Having benumbed the 
parts with cocaine, I introduced a probe, 
wound with cotton, beyond this point of 
contact and brought out some cheesy mat- 
ter of disagreeable odor. I was unable to 
get a thorough view of the nasal cavities 
at that time so I directed her to return on 
the following day; then I found the oeda- 
matous swelling somewhat subsided and 
saw that there was a polypoid enlarge- 
ment of the middle turbinated bodies 
which acted as a valve to imprison the de- 
composing material. 

This I removed with cold wire snare. 
And thus opened up a regular cavity on 
each side, from which I removed at least 
an ounce of foul-smelling cheesy pus. I 
might add that this accumulation was 
above the middle turbinateds so far as I 
could make out. As the parts were thus 
opened, and the discharge was enabled to 
make an exit, it gave rise, by running down 
into the throat, to a very distressing nau- 
sea. This I succeeded in relieving by 
daily removing these secretions and spray- 
ing the nares with a solution of peroxide 
of hydrogen, " Marchand," one to four of 
water, and a mixture, taken internally, of 
pepsin and bismuth; I also prescribed 
champagne. Under this treatment the 



July 16, 1892. Communications. 



93 



patient soon began to improve. She re- 
gained her appetite, the stenosis was re- 
lieved, fcetor stopped, and she began to 
gain in flesh and strength, and on the 4th 
of March I permitted her to go home, some 
ten miles, to report occasionally; she con- 
tinued to improve until the 24th of March, 
when she returned complaining of obstruc- 
tion in the right nasal cavity. Then I re- 
moved the last bit of decomposed mucous, 
which had become very much hardened; 
since which time she has remained well. 
I examined her on the 26th of April and 
found the nasal cavities as nearly normal 
as we are accustomed to see them: there 
was no ulceration, nor was there any per- 
foration of the septum, or anything to sug- 
gest to one that a syphilitic process had 
been going on. 

This case has been a very perplexing one 
to me as far as the diagnosis is concerned. 
I cannot regard it as syphilitic, as the 
effect of antisyphilitic remedies was of no 
avail, but positively hurtful, and the case 
got well without any of the results, such 
as perforation of the septum, exfoliation 
of bone, etc. , which we should expect to 
result from such a severe syphilitic mani- 
festation. 

I am perfectly convinced that it was a 
case where the patient was taken with 
acute catarrhal rhinitis and as a result of 
the swelling of the mucous membrane, 
the discharge was retained and becoming 
decomposed gave rise to the train of symp- 
toms occurring in the case. There might 
have been implication of some of the ac- 
cessory sinuses, but I think that there 
was not to any extent at least. In look- 
ing over the literature of this subject as 
far as I have had an opportunity, it is 
surprising how little is to be found. The 
only contribution is from the pen of 
Middlemass Hunt, of Liverpool, which oc- 
curs in the journal of Laryngology, Rhin- 
ology and Otology, page 1, vol. 6, there 
under the head of " Serious Symptoms 
Arising from Retention of Nasal Dis- 
charge," he relates two cases. The first 
was a girl aged 23, who had had the 
trouble for a year with complete stenosis 
of the right nostril. Before coming under 
his care the case had been diagnosed as 
one of malignant disease. He destroyed 
the folds of mucous membrane which held 
the secretion in the nose, and " scooped 
out the putty like material." The case 
resulted in a cure. The second case was 



a widow aged 45. She had about the 
same symptoms except that the neuralgic 
pains were more severe. Her medical at- 
tendant had diagnosed syphilis and had 
salivated her without effect. The same 
foul smelling cheesy material was found 
in the nasal cavity of the right side. He 
adopted the same treatment except that 
he snared the hypertrophied turbinated 
valve, as it were. In his cases, owing to 
the length of time the disease had per- 
sisted, the fold which had obstructed the 
exit of the discharge had become almost 
the same as granulation tissue, while in 
mine, from the short length of time, about 
five months, it was mucous membrane in- 
filtrated .with serum greatly resembling 
true myxoma. His also differs in being 
unilateral, whereas, mine was on both 
sides. His conclusion is this, and I quote 
in his own words: "The sequence of 
events, in the above cases seem to be as 
follows: An acute nasal catarrh, extending 
to one of the accessory cavities, most 
probably the frontal sinus, with swelling 
and inflammatory hypertrophy of the 
mucous membrane. Leading to gradual 
occlusion of the nostril and retention of 
the discharge, which gradually filled the 
nasal cavity, became inspisated, and, 
through pressure gave rise to pain and de- 
formity. Disease of the antrum is ex- 
cluded by the cessation of all symptoms 
after removal of obstruction." 

I wish to say that my patient was well 
before I saw Dr. Hunt's article, but if I 
had seen it sooner it would have been a 
great help to me as well as a relief. And 
now in conclusion, I wish to add that I 
reported this case more because I have 
considered it my duty than for any other 
reason, and I hope it will impress upon 
your minds that cases do occur where 
there may be a foul-smelling cheesy ac- 
cumulation in nasal cavities without 
syphilis or ulceration of the mucous mem- 
brane, notwithstanding what some of our 
best authorities on nose and throat disease 
may hold in their writings. 



CHLORO-AN^EMIA. 

T>. Pyrophosphate of iron (U. S) 1 part. 

ty> Distilled water (boiled) 5 parts. 

Or, 

T> Citrate of iron 3 parts. 

X)s Distilled water (boiled) 10 parts. 

Inject the contents of a Pravaz syrinpe of either of 
these solutions under the skin of the gluteal region. 

— N. Y. Med. Abstr. 



94 



Communications. 



Vol. lxvii 



VENTRAL HERNIA RESULTING 
FROM ABDOMINAL SECTION.* 



By D. TOD GILLIAM, M. D., 

COLUMBUS, OHIO. 



The safeguards against ventral hernia 
are the slippery and vaulted parietal peri- 
toneum which continually shifts the pres- 
sure, the fascia, the interwoven commis- 
sural fibres, the arrangement of the fibres 
of three sets of muscles. The factors con- 
tributing to ventral hernia are a roughened 
and sacculated peritoneum concentrating 
the pressure, scar tissue which has not the 
power of resistance of normal tissue, and 
the disturbance of relations of the parietal 
components. 

In long standing cases with large and 
pendulous pouch, the viscera become dis- 
placed, the mesentery prolapsed, and the 
cavity properly contracted. This adds 
greatly to the difficulties of the operation, 
because the cavity can no longer accom- 
modate the viscera. 

The ideal operation would be to restore 
a smooth, regular peritoneum, and the 
normal relations of the superimposed 
structures to enlarge the cavity and to 
strengthen the visceral supports. This as 
a rule is impracticable, and the intra-per- 
itoneal operation is fraught with so much 
danger as to condemn it. 

The operation of cutting down to the 
fascia on one side the median line, reflect- 
ing it to an equal distance on the opposite 
side, dissecting up the muscles from the 
middle line outward in both directions, 
overlaping and securing them by suture, 
is full of difficulties, and while offering 
many advantages over the direct median 
section, is not likely to come into general 
use. 

The operation of election must be sim- 
ple, safe, easy of execution and lasting in 
its results. A preliminary treatment is 
necessary to enlarge the cavity, restore the 
viscera and strengthen the muscles. This 
will consist in keeping the patient recum- 
bent, regulating the bowels, massage, the 
Trendelenberg posture, and the use of 
remedies to combat flatulence. The utmost 
care is necessary to secure asepis, for the 
efficacy of the operation depends upon the 

*Abstract of paper read before Ohio State Med - 
ieal Society, May 6, 1892. 



avoidance of suppuration. The operation 
will consist in an elliptical denudation of 
an inch or more in width, around the 
margin of the hernial pouch, and to the 
depth of the fascia, infolding of the her- 
nial pouch towards the cavity, and seried 
layers of buried catgut sutures so as to 
coapt the denuded surfaces perfectly. 
The dressings consist of antiseptic gauze 
held in place by strips of adhesive piaster 
anchored well down on the sides and tied 
with tapes over the median line. Over all, 
the cotton pad and flannel bandage. 



ECLAMPSIA AND SEPTICEMIA. 

Loviot (Nouv. Arch. d 1 Obstet. et de 
Gynec, November, 1891, Supplement, p. 
482) describes a highly-complex labor 
where the patient was saved after extreme 
complications. She was a primipara, aged 
twenty-seven. Loviot found her in labor 
at term, and very badly nursed. The first 
twin presented at the breech ; the forceps 
were applied and it was delivered. Then 
the patient was allowed to rest for an hour, 
the pains being very feeble in the mean- 
time. The head presented, the membranes 
were ruptured, the forceps applied, and 
the child safely delivered. The twins were 
males and both alive ; there were two plac- 
entae. The patient's previous medical at- 
tendant had detected a great quantity of 
albumin in the urine. Antiseptic solutions 
were injected. Three hours later the pa- 
tient had a fit. She was not treated with 
care; delirium set in and when Loviot was 
called in, two days and a-half after he had 
delivered the child, he found her temper- 
ature 105°, liquid motion pouring away 
from the bowel, and foetid lochia discharg- 
ing from the uterus. A large slough in- 
volved the vulva and a tract of the vagina. 
The slough was scraped away, several lit- 
res of solution of sublimate (twenty-five 
centigrammes to a litre of water) injected 
into the uterus, and the raw surfaces pow- 
dered with iodoform. The vagina was 
drained with iodoform gauze. The next 
day the curette was applied to the uterus, 
which was drained with the same dressing. 
At the end of the third week there was 
slight phlebitis in the right leg, which 
lasted six days. The patient shortly after- 
wards left for the country, her health be- 
ing perfectly re-established, excepting that 
the urine contained a trace of albumin. — 
Brit. Med. Jour. 



July 16, 1892. Communications. 



95 



INFANTILE PARALYSIS.* 



By D. R. BROWER,M. D., 

CHICAGO, ILL. 



Polio- Myelitis Anterior Acuta, Essen- 
tial Paralysis of Infancy or Acute Trophic 
Paralysis of Childhood is an affection of 
the spinal cord characterized by a sudden 
febrile onset, often-times with general 
convulsions and a paralysis of variable 
distribution, with a rapid atrophy of the 
paralyzed muscles, and an absence of sen- 
sory disturbance and of disorder of the 
functions of the rectum and bladder. 

Its causation is involved in mystery; 
while it does sometimes occur in adults, 
yet it is essentially a disease of infancy, 
cases occurring most frequently between 
the ages of six months and four years. 
There does not seem to be any well mark- 
ed heredity, but it has an ^etiological re- 
lation to the seasons of the year, occurring 
most frequently in the summer months. 
Dr. Sinkler, of Philadelphia, in an exami- 
nation of a great many cases, determined 
that four-fifths of the cases occurred dur- 
ing the hot months. 

Traumatic influences have been suppos- 
ed by some to have an important causal 
relation. The acute febrile affections not 
infrequently have preceded the develop- 
ment of this disease. 

There is no proof that the disease bears 
any relation to the processes of dentition. 
The rapid functional development of the 
nervous system between the periods of life 
in which it has its greatest frequency, 
having probably more to do with its de- 
velopment at this time than any physio- 
logical process of the body. 

Symptoms. — The clinical history of the 
affection divides itself into four periods: 
First, the period of invasion, which lasts 
from a few hours to a week ; second, a 
stationary period, which lasts for a week 
or a month ; third, a stage of regression of 
paralytic phenomena, lasting from one to 
six months, said, fourth, a chronic stage 
of an indefinite duration. The period of 
invasion begins usually with febrile excite- 
ment, the temperature reaching 103° or 
104 deg., and sometimes 105 deg. Con- 
vulsions occasionally attend the onset, 
especially in young children ;there is more 

*Read before the Illinois State Medical Soci- 
ety, May, 18, 1892. 



or less pain in the back ; vomiting and 
diarrhoea are not infrequent accompani- 
ments; indeed, this onset presents constitu- 
tional disturbances very much like the 
ordinary febriculae of childhood, and I 
know of no means by which its differen- 
tiation can certainly be established. I 
think if we are called to see a patient in 
this stage of the disease we will very rarely, 
if ever, apprehend the cause of the con- 
stitutional symptoms, but in a day or two 
the child will be found to be paralyzed in 
some muscles, or groups of muscles. This 
paralysis is always rapidly developed; only 
a part of a limb may be affected, or both 
arms, both legs, or a leg and one arm may 
be paralyzed. 

The amount of paralysis found to be 
present in this, the second stage of the 
disease, always reaches its maximum almost 
immediately — it possesses no progressive 
character. The sensibility is almost en- 
tirely undisturbed throughout the whole 
progress of the disease ; at the very onset 
they may complain of pains, but these 
painful symptoms are of short duration. 
Reflex function, superficial and deep, is 
abolished in all the muscles that are para- 
lyzed. The functions of the bladder and 
rectum usually escape involvement, ex- 
cept during the first few day there may 
be trouble with both these organs, but 
whatever disturbance there is in these 
functions after a few days disappear. 

After a certain time the period of re- 
gression begins during which the paraly- 
sis disappears, except from certain parts 
in which atrophy occurs. There are 
certain cases in which recovery may be 
complete and it has been proposed to call 
these cases temporary spinal paralysis, 
but as a rule a certain number of muscles 
undergo very rapid recovery. 

The temperature of the paralyzed limbs 
is lower than the corresponding sound 
one, the difference usually being several 
degrees. The sensibility of the skin of 
the paralyzed limbs is not impaired. 
These atrophied muscles will not respond 
as a rule, to Faradic electricity, but 
usually do respond to interrupted galvanic 
currents of sufficient degree of intensity. 
During this period of atrophy there is 
arrest of development in the osseous sys- 
tem so that the limb gradually becomes 
shorter than its fellow, and the difference 
in size increases with the amount of gen- 
eral growth, hence this difference is greater 



96 Communications. Vol. lxvii 



the younger the patient at the onset of 
the disease. There is also during this 
stage, a great tendency to the occurrence 
of permanent shortening of the muscles 
and consequent displacement of the parts 
to which they are attached, deformities 
are thus produced. Certain muscles of 
the lower extremities suffer more fre- 
quently than others with permanent par- 
alysis, and of these, the antero-external 
group of the leg, the long extensor of the 
toes, the tibialis anticus, the superficial 
extensor of the great toe, and the long 
and short perinei are those most com- 
monly affected. When the upper extrem- 
ity is the seat of paralysis, the extensor 
muscles of the hand are those most fre- 
quently paralyzed. Bed- sores, or atrophic 
ulcerations of the skin are exceedingly 
rare. Kelapses are very rare, and second 
attacks are almost unknown ; but a single 
instance of this kind has come under my 
observation. Occasionally, however, the 
disease occurring in childhood seems to lay 
the foundation for the development of 
other spinal affections later in life ; lateral 
sclerosis, posterior spinal sclerosis and 
progressive muscular atrophy occasionally 
follow in the adult period. 

Pathology. — This disease is due to an 
inflammation that has its beginning either 
in the interstitial tissue, or in the paren- 
chymatous tissue of the anterior horns of 
the spinal cord, and either as a consequence 
of the essential parenchymatous inflamma- 
tion, or as a consequence of this interstital 
inflammation there is destruction of the 
cells of the anterior horns of the spinal 
cord, and these cells being motor and 
trophic in function, their destruction re- 
sults in wasting and paralysis. In some 
very severe cases there is a slight local 
meningitis. The original disturbance of 
function being very much greater than the 
amount of degeneration that has been pro- 
duced, results in the clinical fact that the 
paralysis immediately following the onset 
is very much greater than that which is to 
be present after a few days. The proba- 
bility is, that this inflammatory disturb- 
ance has its origin in the presence in the 
blood of some pathological germs. 

Diagnosis. — As already stated, it is 
almost impossible to make a diagnosis in 
childhood of the invasion period; the dif- 
ferentiation of the paralysis depends upon 
the fact that the atrophy is rapid, that the 
temperature of the limb is below normal, 



that there are no sensory disturbances, and 
the bladder and rectum perform their 
functions normally. 

Prognosis. — Occasionally children die 
in the acute onset, doubtless without the 
precise cause of death being determined: 
beyond this there is no danger to life. The 
prognosis as to recovery is to be based upon 
the condition of the paralyzed muscles; if 
the muscles have not lost their electrical 
irritability, then there is hope of recovery 
to a greater or less extent, but otherwise, 
the prognosis as to recovery is absolutely 
unfavorable. 

Treatment. — The treatment of the acute 
stage of the disease consists in the admin- 
istration of antipyretics: Antipyrin, bro- 
mide of sodium, salicylate of sodium and 
ergot, if the disease can be recognized in 
this stage. When the acute stage is over, 
then the tonics are indicated, iron, quinine 
and strychnia in the beginning, cautiously. 
In some cases cod-liver oil and the syrup 
of hypophosphites are extremely useful. 
The most important agent in the treatment 
of this affection is electricity, and the con- 
stant galvanic current should be used as 
soon as the fever has subsided, and should 
be made to pass through the seat of the 
lesion in the cord. The electrodes used 
should be large, and the current should be 
mild and its duration should be five to ten 
minutes. At a later period of the disease, 
when atrophy of the muscles has set in, 
the interrupted galvanic current should be 
used to the paralyzed muscles, of the least 
strength that will produce muscular re- 
sponse, and each paralyzed muscle or each 
group of muscles should be made to respond 
to this electrical stimulus not more than 
once or twice at each seance. As the mus- 
cles improve in tonus, less strength of cur- 
rent will be necessary, and after a time the 
muscles respond to the Faradic stimulation. 

The electricity should be applied by the 
physician in person, much of the want of 
success in the treatment of this disease 
being due to the non-observance of this 
rule. It is a common experience for me 
to be consulted by the friends of these pa- 
tients and when I advise the use of elec- 
tricity to be told that they have been using 
it, and it has been of no value; and upon 
further investigation find that they have 
themselves been applying the current from 
a Faradic battery, that was incapable of 
producing the slightest muscular reaction. 
It is the rule that the Faradic current will 



July 16, 1892. 



Society Reports. 



97 



not produce muscular response, hence its 
use under such circumstances even by the 
physician is useless. 

Along with the electricity there should 
be used massage of the paralyzed limbs, 
and if the nutrition of the muscles does 
not improve under the stimulus of electri- 
city and massage, then stimulating appli- 
cations may be made to the surface of the 
limb, and for this purpose we prefer to use 
the capsicum plaster ; placing around the 
paralyzed limbs strips of plaster about from 
Y% to of an inch in diameter, which 
are to be worn for two or three days and 
then renewed, and if after a reasonable 
space of time, the limbs do not improve 
under this treatment, then I advise the 
use of deep injections of strychnine, pre- 
ferring the nitrate of strychnine as less ir- 
ritating, using full dose, and- giving one 
injection every day. 

This treatment must be persisted in for 
months, even though but little if any im- 
provement is at first noticed, but even the 
most unpromising cases will occasionally 
yield to the treatment if perseveringly pur- 
sued. The occurrence of deformities will 
require appropriate surgical treatment, 
but should not cause us to stop the use of 
remedial measures. During the progress 
of this treatment, the child should be en- 
couraged in every possible way to use the 
paralyzed muscles, and, of course, every 
possible attention should be given to the 
hygiene of the patient, for that condition 
of living that results in the best general 
vigor, will be of the most service in cor- 
recting this special disturbance of nutri- 
tion. 



©octet? IReports, 



CLINICAL SOCIETY OF LOUIS- 
VILLE. 



ICHTHYOL EST SORE NIPPLES. 

Dr. Oehren {Therapeutische Monats- 
hefte, ISTo. 2, 1892) recommends ichthyol 
in the treatment of sore nipples, and ac- 
cording to the following formula : 

T> Ichthyol * gms. 4 (5j). 

_LX Lanoline I - - 5 (r .- V) 

Glycerine f aa gms - 5 K ° m >' 

Olive oil gms. 10 (oijss). 

The advantages of this salve are: One 
application causes the terrific pains to dis- 
appear, the fissures quickly heal, without 
it being necessary to wean the child or to 
use a protective cap. The consistence is 
such that it is easily washed off after being 
applied, and at the same time the salve 
contains nothing that will harm the child. 



Stated Meeting, June 7th, 1892. 



The President, Dr. P. Gtj^ter^iaxx, 
in the Chair. 

FREE DRAINAGE IH PURULENT PLEUEITIC 
EFFUSION. 

Dr. J. M. Keim: In substantiation of 
the belief in free drainage, I simply want to 
exhibit a case upon which this was practic- 
ed, the patient suffering at the time from 
purulent pleuritic effusion. I further 
wish to state that I believe this is the only 
reliable mode of treatment in all such cases. 
This girl when seven years of age had an 
attack of typhoid pneumonia, and about 
four or five weeks after she was convales- 
cent from that trouble, the left side of the 
chest began to bulge and swell, with 
difficult respiration, which continued until 
it made a considerable bulge right where 
you see the scar. It was then opened and 
a small drainage tube inserted, which was 
allowed to remain for six months. She 
had some fever and rigors occasionally, but 
not to amount to anything. The patient 
is now in very good health, except that 
there is a little dullness on percussion over 
that side. She is now about fourteen 
years of age, and the menstrual function 
has been established. 

Case Xo. 2. — This is also a case that 
passed through a siege of pleuro-pneu- 
monia, of about five weeks" duration. 
About four weeks after he was taken with 
pneumonia, there was considerable bulging 
of the right side, with difficulty in respira- 
tion, temperature varying between 100° 
and 103°, and more or less cough. After 
the respiration began to be more impeded, 
I used the aspirator and drew off about 
a pint and a half of dark greenish purulent 
substance, which gave him considerable 
relief. In about two weeks it had again 
filled up and another aspiration was done, 
and about a half pint of liquid drawn off. 
In about three weeks it commenced filling 
up again, cough became more severe and 
one day in stooping down the abscess 
broke into the broncha, and he expectorat- 
ed a great quantity of the material. I 
intended to put in a drainage tube on Xo- 



98 



Society Reports. 



Vol. lxvii 



vember 10th, and the abscess bursted on the 
9th. Patient has improved ever since. 
It was about nine weeks after the first as- 
piration before it bursted. 

Case No 3. — I am sorry that the sub- 
ject of this case was not able to be present 
this evening. The patient is a young lady 
aged twenty-two years whom I saw about 
the middle of October last suffering with 
an acute attack of rheumatic trouble. All 
the large joints were involved, and she had 
been sick about two weeks before I saw 
her. I made a thorough examination, 
found she suffered with mitral regurgita- 
tion in addition to the rheumatic trouble, 
and she told me she had suffered with 
heart trouble since the first attack of rheu- 
matism about ten years ago, which has oc- 
curred every two years since. Two weeks 
after she came under my treatment, I 
found there was considerable oedema on 
the left side with impaired respiration and 
complication of the pleura. 1 thought it 
was possibly due to some conditional heart 
trouble. 1 put her under treatment with 
salicylate of soda with the hope that it 
would remedy it, but the side continued 
to enlarge. I used the aspirator and drew 
off about a pint of fluid; it was not a pur- 
ulent matter however, just a plain pleuri- 
tic effusion. She recovered from this and 
about six weeks afterward the right side 
began to get large. I called Dr. Bailey 
in consultation and lie thought it was 
probably due to effusion. We used the 
aspirator and drew off about a pint and a 
half of purulent substance; it filled up 
again in about three weeks, and 1 then 
used a large trocar inserting a drainage 
tube through the canula after withdrawing 
the trocar. The tube remained in about 
two months draining off everything, and 
she fully recovered. I cannot understand 
why it should have been simply pleuritic 
effusion of the left side, and purulent on 
the other side. 

Case No. 4. — This is a case of tubercu- 
lar origin. I saw the patient for the first 
time in March, 1890; there was consolida- 
tion of the right lung, temperature vary- 
ing between 101° and 103.5°. About three 
months later he had a slight haemorrhage, 
from which he made a fairly good recovery. 
In May, 1890, there was considerable 
oedema on the right ride ; he was aspirated 
and about a pint of dark greenish purulent 
substance drawn off. In about three weeks 
we had to aspirate a second time. On the 



3rd of July, last year, we made a resection, 
taking out about an inch of rib, removing 
about half a gallon of the purulent ma- 
terial, and the discharge has continued 
ever since. He is now gaining in flesh 
and is looking better than he has for quite 
a while. There is not much tube inserted 
now, about half or three-quarters of an 
inch; the opening is gradually closing tip ; 
he does not have any hectic condition. I 
had the discharge examined microscopi- 
cally and chemically, and the results 
showed that it was tubercular trouble. 
The patient is now twenty-six years of age ; 
two sisters have died with tubercular 
trouble ; both father and mother are healthy. 
You will notice in walking he has a peculiar 
gait, slightly favoring the right side. 

Case No. 5. — There is another case that 
I want to report, that unfortunately died. 
It is a case of diabetes ; patient had been 
suffering about six months before I was 
called. An examination of the urine re- 
vealed about ten per cent, of sugar. He 
had been voiding about six to ten pints of 
urine in the twenty-four hours. His right 
side was considerably oedematous, breath- 
ing difficult, hectic condition, etc. I as- 
pirated him and drew off about two pints 
of fetid, dark, bloody looking liquid, and 
it filled up again in about two weeks. I 
then used a trocar, inserting a small drain- 
age tube, which gave him considerable re- 
lief, but unfortunately the man died in 
the course of about ten days after drain- 
age was put in, I suppose from gangrenous 
condition of the lung. I simply wanted 
to make the statement that I would sub- 
stantiate all those who advocate free drain- 
age. After the diagnosis had been thor- 
oughly made, I certainly would not at- 
tempt a second inspiration, but would use 
free drainage. It might be modified some- 
times, and instead of making a resection, 
introduce a trocar and rubber tubing 
through the canula. 

discussion. 

Dr. T. Satterwhite: I would like to 
ask Dr. Krim what kind of a tube he used 
in the first case he presented. 

Dr. J. M. Krim: I used a plain rubber 
tube. It was open about six months, and 
discharged I suppose about ten ounces when 
opened. 

Dr. J. A. Ouchterlony: Referring 
to the case of tubercular trouble exhibited 
by Dr. Krim, I would like to enquire if 



July 16, 1892. 



Society Reports. 



99 



there were any tubercular bacilla in the 
sputa before the operation. 

Dr. J. M. Krim : Yes sir, all the char- 
acteristics of tubercular trouble. The 
discharge, however, did not have any 
fetid odor until the last couple of months. 

Dr. J. A. Ouchterlony : What is the 
patient's temperature at the present time? 

Dr. J. M. Krim: Temperature is 
about 99°, sometimes a little more, then 
again normal. 

Dr. J. A. Ouchterlony: Have the 
bacilla disappeared from the discharge 
now ? 

Dr. J. M. Krim: No sir, they have 
not. 

Dr. T. Satterwhite : I would like to 
ask if the patient has any cough at this 
time. 

Dr. J. M. Krim : He has some cough, 
principally in the morning, and some 
little expectoration, The discharge is very 
slight during the day, increasing at night 
when the patient lies down. 

Dr. J. A. Ouchterlony: I regret 
very much that I did not hear report of 
the other cases but the one I was fortunate 
enough to see is certainly exceedingly in- 
teresting, and it suggested to my mind 
some points concerning the combination of 
pleurisy with pulmonary tuberculosis. 
We are aware that pleurisy in connection 
with tuberculosis is quite common, and I 
would mention in passing that when it 
does occur, save in the form of plastic, it 
is • generally of a suppurative variety. 
Under such circumstances not only is it 
good practice to do as Dr. Krim suggests, 
to open the pleural cavity and establish 
drainage, but it seems to me that it affords 
most excellent opportunity for bringing 
the anti-tuberculosis treatment to bear in a 
manner that cannot ordinarily be done, 
attacking the disease by means of copious 
washing out with carbolized solutions. I 
thinkgwe should continue to wash out the 
cavity under such circumstances with car- 
bolized solutions of the proper strength, 
as long as any remains of the cavity exists. 
That there are tubercular processes going 
on in the pleuritic cavity, as well as in the 
lung itself, is proven by the fact that 
tubercular bacilli were found. 

As to removing a portion of rib in tub- 
ercular pleurisy — I do not know that it is 
entirely free from objections, because it 
may lay the patient liable to danger of in- 
fection of the ribs with tubercular bacilli. 



My preference in a vast majority of cases 
of suppurative pleurisy that I have seen 
would be decidely in favor of using a large 
rubber tube. Indeed, I have not had a 
case in my practice within the last ten or 
twelve years where it has been necessary 
to resort to the exsection of a rib. I de- 
vised a self retaining rubber tube much 
larger than the largest trocar, by means of 
which the opening can be kept as fully 
pervious as desired, and affords a most ex- 
cellent opportunity for washing out the 
pleural cavity. The ordinary soft cathe- 
ter used I do not think sufficient, as a 
rule, and it has the disadvantage that 
there is always a possibility that the cathe- 
ter may slip into the pleural cavity. 
Such accidents have occurred in a number 
of cases, and have necessitated the per- 
formance of an operation of some magni- 
tude in order to correct them. The tube 
I have devised has a flange which prevents 
it from entering the cavity. 

Dr. J. W. Irwin: The remarks made 
by Dr. Ouchterlony seem to be about all 
that can be said upon the subject. With 
reference to the operation for removal of 
pus from the pleural cavity — several years 
ago I had made by Mr Armstrong an in- 
strument for entering the intercostal 
space, which is quite narrow. It is very 
hard to get a canula of suitable size be- 
tween the ribs. I had made a flat canula 
and trocar so that I could insert it between 
the ribs by elevating the elbow as far as it 
could be elevated, and in that way could 
get free drainage of the pleural sac very 
much easier than by ordinary means of as- 
piration,and I subsequently as Dr. Ouchter- 
lony has just said, inserted a rubber drain- 
age tube allowing it to stick out far 
enough so that it could not be drawn into 
the chest. 

Now, as to the method of washing out 
the chest in consumptives — I have had 
considerable experience in that. I remem- 
ber one case that I will mention briefly : 
The patient was a large fleshy man, (in the 
employ of a brewery), who had inherited 
consumption, and during the first year of 
the disease, he developed quite a sac of pus 
in the pleural cavity and it became neces- 
sary to evacuate it. I evacuated it in the 
manner described, and injected every other 
day from a pint to a quart of carbolized 
solution, %yi per cent, of pure carbolic acid, 
into the cavity of the chest. He improved 
for a while very rapidly, and it seemed that 



100 



Society Reports. 



Vol. lxvii 



he would get well, but gangrene set in and 
he became rapidly worse and died. In 
another case that came under my observa- 
tion, I used a three per cent, solution of 
tincture of iodine, injecting from a pint to 
a quart — it took that much to wash out 
the cavity — the same results followed as 
in the case mentioned. In both instances 
the washing seemed to produce a decided 
improvement for a short time,, but subse- 
quent results hastened death. 

De. T. Satterwhite: Referring again 
to the first case exhibited by Dr. Krim : I 
notice that the opening was made rather 
high, and think it would have been bene- 
ficial if an incision had been made lower 
so as to have used a syringe from above 
downward. However, the results show 
that the child made an excellent recovery. 
I remember a number of years ago, a child 
about nine years of age had a very exces- 
sive effusion and I made a silver tube with 
a flange which was inserted and the cavity 
washed out regularly for two or three 
months. The child had the most excessive 
curvature of the spine that I have ever 
seen, resulting from collapse of that side, 
but by practicing inflation of the lung- 
it evidently broke up the adhesions and 
and the curvature entirely disappeared. The 
second case reminds me of one that I saw 
some time ago in connection with one of 
the members of this society: There was 
very considerable fullness of the right side 
of the chest, the lower half or two-thirds. 
A portion of the rib (probably about two 
inches) was trephined expecting fully as 
soon as we did so, that pus would gush 
out, but no pus came. We concluded that 
we ought to put in a drainage tube but 
were at loss to know exactly what course 
to pursue. The next morning there was 
a very free discharge of pus, I suppose 
about two or three pints. My idea was 
that there was no effusion, but that it was 
an abscess of the lung. There was com- 
plete dullness, we could hear no respira- 
tion at all in the lower part of the chest, 
and there was also bulging so we diagnos- 
ticated pleuritic trouble. It came on in 
the way that these pleuritic effusious usu- 
ally come. 

Dr. W. T. Dulaney, (of Bristol, 
Tenn.): — I have had a little experience 
with this character of cases, not a great 
deal, but what I had came thick and fast. 
I had three cases within eighteen months 
about the year 1885 ; one was a very re- 



markable case, and illustrates the impor- 
tance of washing and drainage. I will re- 
port them briefly : — The first subject was a 
young man about twenty years of age, 
very stout and vigorous previous to the at- 
tack to which I refer. About the first of 
January, 1886, he danced all night and 
soon after took a trip by rail and was sub- 
sequently attacked with what his physician 
(a very good one) called pleuro-pneumonia. 
I was not called to see him until May — 
found him suffering with general anasarca, 
very much swollen all over, could not lie 
down, breathing was very rapid, pulse over 
140, left side of chest filled with fluid, and 
he was depending upon one lung for res- 
piration. I did not have an aspirator at 
the time, but relieved his general oedema 
by puncturing his back, legs, etc., and in 
a day or two it all drained out. He was 
then in such condition that I could make 
a more thorough examination. We aspir- 
ated him about the eighth intercostal 
space behind, and drew off about eight 
pounds of pus having a sort of muddy ap- 
pearance. Of course there was immediate 
relief from the distressing symptoms, pulse 
came down to normal in less than twenty- 
four hours. In two weeks, he was as full 
as ever; we operated again drew off this 
time about nine pounds of pus. The cav- 
ity was thoroughly washed out at each as- 
piration with carbolized water. Two 
weeks after the second aspiration he was 
fuller than ever; we used a trocar this 
time, but just as we were about ready to 
operate the abscess broke into the lungs 
and quite a quantity of very offensive pus 
come out by way of the bronchial appar- 
atus. Previous to this there had been no 
odor about the pus whatever. We removed 
with the trocar about eleven pounds of pus, 
then inserted a small drainage tube, wash- 
ing the cavity each day. In the course of 
two months while under treatment, we 
calculated that we removed from this pa- 
tient about seventy pounds of pus. He 
made a good recovery and is now as strong 
and vigorous as ever, and is doing hard 
work as a plumber. 

A short time afterward I was called to 
see a case that another doctor had tapped 
with a trocar, the patient was a little girl 
about two years of age, pale, thin, and as 
poor as anybody could be, financially — I 
merely mention this to show the surround- 
ings. We used the trocar and drew off 
quite a quantity of pus and washed it out 



July 16, 1892. 



Society Reports. 



101 



thoroughly with carbolized water. The 
child made a good recovery. 

The next case was a boy about eight 
years old, who had an abscess very low 
down, in fact, so low that I thought it 
possibly might be some hepatic trouble. 
It was on the right side. This child had 
always been in the habit of haying his own 
way, and would not have it opened for 
about eight months, but it was discharg- 
ing a little. The little fellow had become 
very much reduced, and I did not think 
he would ever get well. The abscess was 
opened in front, thorough drainage estab- 
lished, washed out with carbolized water 
every day, and the patient made a good re- 
covery. 

I regarded the first case as a very inter- 
esting one on account of the quantity of 
pus removed. The heart was dislocated, 
as far to the right side before the operation 
as it should be to the left in the normal 
state. 

Dr. W. 0. Roberts : I have had quite 
a large experience in the treatment of em- 
pyema; have seen only one case of true 
empyema die after drainage was establish- 
ed. That case occurred in the city hos- 
pital and was doing well, when a case of 
erysipelas was brought into the hospital, 
and this patient among others became 
affected and died. In the majority of my 
cases the trouble has been on the left side. 
I have seen two cases in which there was 
spontaneous opening, and in each case it 
occurred high up in the region of the nip- 
ple and would only drain, of course, when 
the fluid reach a level with the opening, or 
the patient would lie down. I operated 
upon one of these patients a few weeks ago. 
He was a graduate of the University. In 
this case the empyema was on the right 
side. An opening was made in the seventh 
intercostal space, and he recovered without 
an untoward symptom. 

In regard to the removal of a portion 
of ribs — my rule has always been when- 
ever I can insert my little finger between 
the ribs, and that is, when there is suffi- 
cient space to admit of the introduction 
of a large sized tube, no interference with 
the ribs is necessary. But where this can- 
not be done it is then necessary to remove 
a section of rip. As to the use of the 
aspirator, I think the cases reported this 
evening prove the folly of attempting to 
treat or cure these cases by use of the as- 
pirator. They invariably refill. The as- 



pirator, I think, is only of use as a means 
of diagnosis. I believe an opening ought 
to be made just as soon as pus is discovered. 
Another point of great importance is the 
washing out of the chest: The weight of 
authority is against washing out the pleu- 
ral sac, unless there is evidence of fetid 
discharge. As long as the discharge is 
sweet, it is not necessary to wash out the 
chest. There is a great deal of danger in 
washing the pleural cavity when you dis- 
tend it to any great degree. A number 
of cases of sudden death have occurred 
from over-distension of the pleural sac. 
A point of considerable importance in the 
treatment of these cases after a tube has 
been introduced, is the use of an abund- 
ance of absorbent gauze, (not cotton but 
gauze) so that every particle of discharge 
may be absorbed as soon as it comes to the 
mouth of the tube. Recovery in many of 
these cases is delayed by neglect of this 
provision. 

Dr. J. A. Ouchterlony: One reason 
for using the aspirator is to get immediate 
relief, when the patient is suffering with 
great interference either of respiration or 
circulation. 

Dr. J. M. Krim: Concerning resection 
of the rib — I cannot see anything wrong 
about this. In all cases that I have 
treated and others that have come under 
my observation, I have never seen any bad 
symptoms or results from resection ; still, 
I am inclined to do just as Dr. Roberts 
states, and as before mentioned by me, if 
you can introduce in the intercostal space 
a large sized trocar and so establish drain- 
age, it might sometimes be preferable to 
pleurotomy. But I do believe where 
there is no chance to get a good sized 
trocar in between the intercostal space, 
that resection is not going to do any 
harm. 

In regard to washing out the cavity 
In none of the cases I reported to-night 
was there any washing out done, except in 
one or two instances where the discharge 
had become offensive. As long as there 
was no fetid discharge the cavity was not 
washed, and all the patients improved very 
nicely. 

Dr. J. A. Ouchterlony: My remarks 
w r ere especially in reference to the last case 
exibited by Dr. Krim, which is a case of 
tubercular suppurative pleurisy. I do not 
think there can be any doubt that having 
tuberculous fluid flowing over the porous 



102 



Society Reports. 



Vol. lxvii 



structure of the rib, lays it liable to tuber- 
culous infection. 

Dr. W. 0. Roberts: When it becomes 
necessary in tubercular trouble, to remove 
a portion of rib. would it not be a good 
idea to have the ends of the bone cauter- 
ized with the hot iron? 

Dr. J. A. Ouchterlony: There is 
one objection to the removal of a portion 
of rib that I have noticed very frequently 
— and I have seen a great many cases of 
pleurisy, with effusion, both suppurative 
and non-suppurative — it is this, new bone 
forms with great rapidity, and the ten- 
dency to closure of the opening is very 
great by the formation of bony material. 
I have had cases under my care where ex- 
section of a piece of rib has been made^ 
and where the opening has been reduced 
to a minimum in a very short time. With 
me the point has always been whether it 
was not better to resort to the least severe 
operation if it will do; of course, if it is 
not adequate to meet the indications of the 
case, why then remove a piece of rib by all 
means. 

Dr. W. T. Dulaney : Last fall a young 
man, conductor on a freight train, in Vir- 
ginia, was shot by a tramp. I saw the 
patient about six weeks afterward and 
found the ball had entered at about the 
seventh intercostal space in front; there 
was general dullness all over the left side 
of the chest; he had no bloody expectora- 
tion and no cough, nor had there been any, 
but there was a little bulging at about 
the tenth rib behind. After consultation 
with the attending physician, Dr. Butler, 
we decided to make an incision there and 
when we reached the cavity, there was a 
gush of fetid pus, and serum, I suppose 
about two pints, and, upon enlarging the 
incision we found that the tenth rib had 
been broken by the ball passing through it, 
about two inches from the spinal column. 
While examining the wound as the pus and 
serum came out, the hole suddenly became 
plugged with a substance which looked 
like dead cellular tissue, or lung. I took 
hold of it and pulled out quite a quantity 
of the most effensive material that I have 
ever seen ; it looked to me very much like 
dead lung tissue. About a double handful 
of it was removed. We found the ball 
just outside of the rib deep under the 
muscles of the back. The patient in the 
meantime had considerable fever. The 
wound was thoroughly washed out and the 



patient put to bed. In a day or two in 
giving him an enema, we were 
greatly surprised to see the water come 
out at the opening in the back. I had 
some doubts about this being the water 
used in the enema, so we used some colored 
water which also came out through the 
hole. The fever went down and the 
patient slowly recovered. He had fecal 
discharges from the opening for two or 
three months, and especially if they were 
fluid. The opening finally healed, and 
the man recovered though with impaired 
strength and diminished capacity. 

Dr. W. 0. Roberts: I would like to 
ask Dr. Dulaney if the material removed 
was a solid mass. 

Dr. W. T. Dulaney: It may have been 
the result of haemorrhage at the time the 
shot was received ; it was a speckled mass 
looking like cells of the lung, in fact it 
looked like dead lung tissue. The hole was 
plugged up completely and we kept pulling 
out piece after piece of the offensive 
material, and, when we found the fistula, 
I did not know what was going to become 
of it. When the fecal discharges were a 
little thin or fluid, it would just pour out 
of the hole. I suppose it was the result 
of some inflammatory adhesions of the 
transverse colon to^the diaphragm, which 
sloughed through. 

DILATATION OF RIGHT SIDE OF HEART, 
WITH VALVULAR INSUFFICIENCY. 

Dr. J. W. Irwin: I want to speak of 
a case that came to my notice some days 
ago. A man, a poor looking individual 
with a hospital shirt on, came into my office 
one day puffing and blowing, and said he 
wanted to be examined. He was forty- 
years of age and evidently had been an 
Irish laborer. He gave the history of hav- 
ing been at work for the Western Union 
Telegraph Co., raising a telegraph pole, 
and while doing so a spike pole that was 
resting against the telegraph pole with 
the spike end up, fell on his head striking 
on the upper portion of the occipital bone, 
producing some contusion over that region, 
and considerable swelling but no fracture. 
There was no laceration of the scalp and 
the injury did not give him much incon- 
venience as he continued at work for 
twelve days. He had some dull pain in 
his head and some little pain in his chest 
about the upper and middle third of the 
sternum ; he also complained of some pain 



July 16, 1892. 



Society Reports, 



103 



in the region of the heart, of a dull aching 
character, but not continuous. There 
was no loss of appetite nor sleep ; his diges- 
tion was good and when resting he felt 
comparatively strong. At the end of 
twelve days the pain in the head grew 
worse, and he then applied for admission 
to the city hospital. This occurred, I 
think, as nearly as I can remember, about 
the first of October, and he remained in 
the hospital ever since. On walking 
about, taking any considerable exercise, his 
face and lips would become of a purplish 
color, the veins in the face and neck be- 
coming immensely enlarged, in fact the 
jugular veins appeared to be one inch in 
diameter. There was no pulsation nor 
murmurs in the veins. The veins over 
the sternum and over the chest were also 
greatly enlarged. One vein extending from 
the right inguinal ring to the axillary and 
sub-scapular veins was very much enlarged 
and tortuous. Some of the veins in the 
lower extremities were also enlarged, some 
of them varicosed. When the patient 
stooped over, his face, hands, arms, finger 
nails, and palms became purple in color. 
When standing erect the face became quite 
blanched, and the veins normal in size. 
His pulse was strong and full when stand- 
ing erect, put when stooping forward the 
pulse grew very feeble on both sides. 
When in a stooping position or upon any 
exertion, he had considerable dyspnoea. 
He had a hacking cough without any ex - 
pectoration; he complained of some dull 
headache at times, which was made worse 
by stopping over. Exertion also caused 
his head to ache. I examined the chest 
by percussion, found increased dullness 
over the region of the heart, extending 
pretty near to the ensif orm appendix of the 
sternum. The sound of the mitral valves 
was short and sharp and heard a little 
toward the right of the left nipple. When 
stooping forward the sounds on both sides 
became muffled, and a faint blowing sound 
could be heard on the right side. There 
was no evidence of aneurism. Pressure 
over the region of the liver caused enlarge- 
ment of the supra-clavicular veins and also 
the vein entering the inguinal ring that I 
have mentioned. The man is not strong, 
that is, he is physically strong enough, but 
on taking any sort of exercise he pants for 
breath. Food improves his condition very 
much. In other words, in half an hour 
after dinner he seemed much better, he 



could walk or stoop without causing any 
dyspnoea. I gave him two ounces of whisky 
which had the same effect on him as food. 
It was evident that both the food and 
whisky increased the power of the heart's 
action. I will state here that he gave the 
history of not being an intemperate man, 
he took a drink occasionally, said he had 
been a laborer for thirty-six years. He 
had never done any very hard work, and 
to use his own expression, had "never 
abused himself in any way. v Never had 
any venereal disease. I diagnosticated di- 
latation of the right side of the heart with 
insufficiency of the tricuspid valves. Time 
Avill not permit my going into differential 
details. I wish further to say that I had 
his urine examined and found it to con- 
tain a small amount of albumin, but no 
casts. There was slight oedema about the 
eyes and ankles. 

CASE OF SPINAL INJURY. 

Dr. W. 0. Roberts: I saw a man day 
before yesterday, a laboring man, thirty 
years of age. Last August he was loading 
a wagon with logs, the wagon was at the 
time about half full. He says that he was 
about eight or ten feet from the ground, 
while standing on the wagon pulling a 
log up with some kind of rope attachment, 
the rope broke or gave way, and he fell 
backward striking on his shoulders; was 
insensible for only a. few minutes. He * 
said when he came to himself he found 
that he had lost all muscular power of the 
body, from the neck down. He was seen 
some little time afterward by a physician 
and upon examination it was found that 
he had not only lost all power of motion 
but also of sensation, from his neck down 
with the exception of his shoulders and 
arms. He has remained in about the 
same condition up to the present time. 
He can raise his arms up, bend his elbows, 
but cannot bend his fingers. He has sen 
sation in his arms, also upon his body on 
a level with the lower boundary of the 
axillary space; below this point there is 
no sensation and no motion. There has 
not been at any time any ecchymosis or 
local evidence of contusion or mark to show 
where he struck the ground. Urine runs 
from him as fast as secreted; he has no 
control over bowels ; when he has diarrhoea 
it just trickles from him all the time, and 
when his bowels are constipated, the nurse 
has to take the fecal matter away with the 



104 



Selected Formulce. 



Vol. lxvii 



fingers. His intellect is as good as it ever 
was. 

Upon examination I could find no de- 
formity whatever about the spine ; between 
the seventh cervical and the first dorsal he 
is sensitive to the touch, but not nearly so 
much so as he was shortly after receipt of 
the injury. He has four large bed sores, 
his legs at first were perfectly straight and 
helpless, but for three or four months the 
muscles have been contracting until now 
there is marked flexion at the knee and at 
the hip, and it is impossible to straighten 
the legs. Before this occurred he says 
that there was considerable oedema in 
both legs ; there is no evidence of that now, 
in fact his legs are very much shrunken. 
It is a question in my mind as to the na- 
ture of the injury, and as to the advisabil- 
ity of an exploratory operation to see 
whether or not there is any fracture of the 
lamina and if such can be found, whether 
its removal or elevation if depressed, would 
be of any benefit to him. There has been 
no priapism. 

SYPHILITIC ULCERATION OF THE REC- 
TUM. 

Hahn (Deut. med. Woch., January 28th, 
1892) reports a case of syphilitic ulceration 
of the rectum in a woman, aged 33 ; there 
was also widespread ulceration in the ileum. 
At the necropsy the mucous membrane was 
found to be of a blackish green color, and 
extensively ulcerated for a distance of 16 
cm. from the anus, with but few islets of 
intact mucous membrane ; most of the co- 
lon was unaffected. In the ileum, at about 
1.5 m. above the ileo-caecal valve, there 
were eleven large ulcers with thick callous 
edges, and at 25 cm. above the valve a 
narrowing of the gut extending over 8 cm. 
There was amyloid disease of the kidneys 
and spleen, and also periosteal thickenings 
over both tibiae. Anterior colotomy had 
been successfully performed during life, 
and there were free evacuations through 
the opening. The vomiting, however, 
persisted, and the author would attribute 
this to the renal disease. Hahn belongs 
to those who think ulcerative proctitis 
(occurring almost exclusively in women) 
is seldom really due to syphilis. After 
other measures have been tried, extirpa- 
tion of the rectum and colotomy alone re- 
main. Some cases, when of limited ex- 
tent, can be cured by the former proced- 
ure. — Brit. Med. Jour. 



Selected jformulae. 



FOR HYPERIDROSIS. 

For the treatment of hyperidrosis in 
general, and for sweating of the feet in 
particular, Brocq (Jour, des Maladies 
Cutan. et Syph., April, 1892) believes that 
the following drugs are of service : 

1. Naphtol — 5 parts. 

Glycerine 10 parts. 

Alcohol 100 parts. 

M. Sig. — Apply locally twice a day, after which a 
powder composed of two parts of naphtol and 180 of 
starch is placed between the toes. 

2. Permanganate of potassium 3 grammes. 

Talc 40 grammes. 

Subnitrate of bismuth 45 grammes. 

Salicylate of sodium 2 grammes. 

Rice powder 60 grammes. 

M. 

Or, 

3. Permanganate of potassium 10 grammes. 

Talc, .... 5 grammes. 

Subnitrate of bismuth 25 grammes. 

M. Sig.— Either powder to be applied every morning. 

4. Sulphate of quinine 5 parts. 

Alcohol at 6° 100 parts. 

Tannin 1 to 3 parts. 

Alcohol at 50° 250 parts. 

M. Sig.— Apply after the feet have been washed, to 
be followed by this powder : 

5. Salicylic acid 3 parts. 

Starch 10 parts. 

Pulverized talc 87 parts. 

Pulverized alum 45 parts. 

6. Perchloride of iron 30 grammes. 

Glycerine 10 grammes. 

Essence of bergamot 20 drops. 

M. Sig.— For two days previously the feet are to be 
washed with a cold infusion of walnut-tree leaves, and on 
the third day the above mixture is applied. 

7. Tincture of belladonna 25 grammes. 

Cologne water 120 grammes. 

M. Sig.— Two or three 'frictions per day. 



FOR ALOPECIA. 

Quinquaud (L' Union Medicate — Journ. 
des Malad. Cutan. et Syphil., April, 1892) 
recommends the following topical applica- 
tion : 

T3, Biniodide of mercury 0.20 gramme. 

-C¥ Bichloride of mercury 1.00 gramme. 

Alcohol at 90 40.00 grammes. 

Distilled water 250.00 grammes. 

M. Sig.— The hair is cut short; then every day, after 
a good shampoo, the above solution is to be applied, night 
and morning. In the mean time frictions may be made 
with a liniment composed of : Balsam of Fioraventi, 100 
grammes; camphorated alcohol, 100 grammes; ammonia, 
6 grammes. For a general treatment the same author 
advises the administration of cod-liver oil during the first 
three weeks of each month, and five to six drops of Fow- 
ler's solution, per day, during tbe fourth week. The 
treatment is to be continued while the hair remains 
fragile. 



FOR CHAPPED HANDS. 

The following mixture, according to 
Baelz {Med. chir. Centralb. Pliarm. Post, 
No. 52, p. 1137, Journ. des Malad. Cutan. 
et Syphil., April, 1892), is of service: 

"D. Caustic potassa 0.5 gramme. 

JQtf Glycerine. 

Alcohol, of each 20.00 grammes. 

Distilled water 60.00 grammes. 

M. Sig.— After washing the hands with warm water, 
the mixture is to be rubbed once every twenty-four hours. 



July 16, 1892. 



Editorial. 



105 



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XeatuttQ articles* 

THE PEOPHYLAXIS OF PITERPE- 
RAL FEVER. 

Dr. J. Veit, is one of the most recent 
numbers of the Berliner Min. Woclien- 
schrift, essayed to answer this question in 
the following, sentence : el In spite of the 
value and usefulness of antiseptics, the 
percentage of women dying from puerpe- 
ral infection remains high even where no 
operative procedure has been undertaken ; 
it must, therefore, be concluded that the 
too frequently resorted, to internal exami- 
nations practised by the physician during 
or after labor exert a harmful effect upon 
the patient, and in themselves constitute 
the medium of infection. 

Viewing the matter from a similar stand- 
point, already a large number of eminent 
obstetricians both here and abroad have 
raised a note of warning against unneces- 
sary examinations of the genital tract 
during childbirth. 

Litzmann, the German obstetrician, 
allows the students at his clinic only to 
make external examinations, finding that 
the slight loss of practical experience is 
more than compensated for by the lessen- 
ing of the death-rate. 

The most recent communications from 
the pens of Orede and Hegar are practi- 
cally only repetitions of these warnings. 
Leopold has also come to the conclusion 
that internal examinations should be 
avoided whenever possible, and adheres 
strictly to this rule in his practice. He 
states from actual experience that the 
mortality from childbirth can be reduced 
to a minimum if internal examinations are 
avoided. 

The Deutsche med. Zeitung in referring 
to the subject, states that in cases of nor- 
mal labor internal examinations can be en- 
tirely replaced by careful external exami- 
nations, and that the former should only 
be undertaken when special indications 
are manifest. 



106 



Editorial. 



Vol. lxvii 



We have touched upon this subject not 
only on account of its vast importance, but 
because it has recently been most actively 
discussed by our European contemporaries ; 
for abroad, as here, it has been the prac- 
tice of most physicians to make an inter- 
nal examination as soon as they reach the 
bed-side. According to these recent in- 
vestigations, during the period of dilata- 
tion of the cervix, an internal examina- 
tion should only be undertaken under the 
following circumstances: First, in cases 
where the condition of the patient is 
greatly impaired — as in eclampsia, neph- 
ritis, fever, bad circulation, etc. ; second, in 
cases where there are local disturbances — 
haemorrhage, abnormally painful labor, or 
an abnormally long period of cervical dila- 
tation ; third, in cases where an external 
examination reveals an abnormal condition 
— such as the head of the foetus over the 
pelvis in primiparae, or after the rupture 
of the amniotic sac in multipara^ an ab- 
normal enlargement of the lower uterine, 
segment, rupture, lessening of the foetal 
heart sounds, or abnormal position of the 
foetus. 

During the period of expulsion an in- 
ternal examination is only admissible under 
the following circumstances : First, in cases 
of general derangement — such as fever, bad 
pulse, great excitement, eclampsia, and 
nephritis; second, in cases of local de- 
rangement — such as delayed rupture of 
the amniotic sac, haemorrhage, insufficient 
labor, or retarded delivery ; third, in cases 
of an unlooked-for change in the position 
of the foetus, abnormal distension of the 
lower segment of the womb threatening 
rupture, lessening of the foetal heart 
sounds, and displacement of the foetal 
head above the pelvis. 

In order to be able to restrict the in- 
ternal examination of parturients to the 
above named conditions, it will, of course, 
be necessary to submit the patient to a 
careful external examination, and indeed 
lay greater stress on the latter than is now 



generally done. It will also be necessary 
for our obstetrical clinics and schools to 
give their students more exact data regard- 
ing external examinations than is now 
generally done. This being accomplished, 
the results of a limitation of the internal 
examination of parturients will be speedily 

felt. 

TREATMENT OF ABSCESS OF THE LIVER. 

Fontan (Rev. de Chir,, February, 1892) 
holds that a simple incision is not always 
sufficient, even when very large, to effect 
a cure of hepatic abscess. Scraping of the 
walls of the abscess was advocated as a 
desirable addition to incision. The scrap- 
ing, it was stated, should be done with a 
blunt curette, guided by the index finger 
passed into the interior of the abscess. 
Two cases were reported in support of the 
author's opinion that such treatment is not 
likely to cause any serious haemorrhage, 
and that it favors rapid and complete cure. 
In the discussion, Pozzi, whilst granting 
that the method might enable the surgeon 
to discover and open a second abscess, said 
this advantage would not compensate for 
such probable dangers as haemorrhage and 
opening of the biliary passage. Monod 
considered the method not only dangerous, 
but also useless. He quoted cases to show 
that incision followed by drainage would 
suffice to bring about a cure of the abscess. 
In one of these cases, however, the ulti- 
mate result was not satisfactory. After 
three unsuccessful exploratory punctures, 
a fourth made in the intercostal space 
revealed the presence of pus in the liver. 
Monod, after removing a portion of rib, 
made a free incision into the abscess and 
drainage the cavity. The condition of the 
patient improved for a time; but subse- 
quently the temperature rose, the diarrhoea 
became more profuse, and death took place 
six weeks after the operation. The original 
abscess, which had been incised and 
drained, was found at the necropsy to be 
quite closed, but there remained two other 
collections — one near the convex surface, 
the other near the inferior surface of the 
liver. The presence of one or more other 
purulent deposits is usually the cause of 
failure of incision in the treatment of hep- 
atic abscess. Unfortunately, Monod 
states, it is very difficult to determine the 
presence of such multiple abscesses. — Brit. 
Med. lour. 



July 16, 1892. 



Book Reviews. 



10? 



Book Reviews. 



DISEASES OF THE URINARY APPAR- 
ATUS, PHLEGMATIC AFFECTIONS. By 
John S. Gouley, M. D., Surgeon to Bellevue 
Hospital, New York. New York : D. Appleton 
and Co., 1892. 

The scholarly attainments of this distin- 
guished New York surgeon have never been 
shown to greater advantage than in this, 
his latest book. Every American surgeon 
is familiar with the thoroughness and 
depth of Dr. Gouley's professional know- 
ledge, his clearness of expression, exact- 
ness of statement, and beauty of style; 
and those who have valued his previous 
writings will read this contribution with 
great satisfaction. The subject is pre- 
sented in its broadest and most compre- 
hensive aspect; principles rather than 
technique and methods being dealt with. 
It may truly be said that this book is a 
fitting evidence of a long life of usefulness, 
clinical research and experience. In every 
page we clearly read that the author has 
recognized above every other consideration 
the paramount value of the great princi- 
ples which underlie the diseases of which 
he speaks, and that he conscientiously 
endeavored to trace as definitely as our 
knowledge will permit the true pathologi- 
cal states concerned in their production. 
It is this admirable foundation which 
gives special value to his work. 

The term phlegmasic affection is his 
own, and by it he means et sl morbid pro- 
cess, one of the local nutritional changes 
which, when visible and tangible, is ordi- 
narily characterized by heat, redness, 
swelling, and pain, and which is now 
believed by many pathologists to be gener- 
ally caused by microbic invasion. " An- 
other term which will attract considerable 
attention is allotrylic affections, meaning, 
as its derivation suggests, ' ' morbid states 
caused by the lodgement of foreign sub- 
stances in the organism?" 

The division the author makes in the 
general pathology of the urinary apparatus 
cannot be too highly praised. It is com- 
plete in itself, and its application to special 
diseases of the urinary apparatus is simply 
perfect. No one can study too carefully 
this excellent chapter. It is in fact the 
foundation of all that follows, and if the 
student gets the truth contained in it 
firmly fixed in his mind he will have a solid 
basis for any subsequent pathological con- 



siderations which may logically be deduced 
from the principles here laid down. 

Among the special considerations none 
is more interesting, more valuable and 
better prepared than the one devoted to 
cystitis; the remarks upon its treatment 
being worthy of special attention. The 
author is a strong opponent of infra- and 
supra-pubic cystotomy for the relief of 
chronic cystitis with contracture of the 
bladder. In these cases he believes that 
the best method of cure is by hydraulic di- 
latation of the bladder. Concerning this 
he remarks : ' ' There is no curative power 
in rest and drainage of the bladder in the 
case of cystitis and contracture. * * * 
The prescription of long rest to the blad- 
der in these cases does not seem rational, 
since it is well known that the prolonged 
immobilization of any part so surely leads 
to its permanent contracture. The mus- 
cular walls of the bladder need be exer- 
cised in cases of cystitis with contracture 
which has not become permanent, and this 
exercise is attainable by hydraulic expan- 
sion, which gradually restores the bladder 
to its normal suppleness and capacity. 1 ' 

In a book like this, every part of which 
is finished, it is useless to attempt to give 
more than (in idea of its general characters, 
which has been very imperfectly attempted 
here. Every surgeon should read it, for 
we are sure that there will not be disap- 
pointment. 



THE SUBCUTANEOUS USE OF IRON IN 
NERVOUS TROUBLES. 

Eosenthal (Pest. Med. Chir. Presse) 
advises this method of administration. He 
has detected the metal in his own urine 
within thirty to forty minutes after injec- 
tion. He recommends two preparations: 
Ferrum peptonitum, produced by adding 
a solution of pepsin to one of ferric chlo- 
ride, producing a powder soluble in water, 
which is given in doses of one syringeful 
of a 10 per cent, solution every other day ; 
and ferrum oleincum, given in the same 
dose in a o per cent, solution in olive 
oil. The former is preferable. He rec- 
ommends this method in delicate neuras- 
thenic individuals, and in the asthenic 
dyspepsia often complicating anaemia, in 
which small doses of iron often produce 
severe digestive disturbances. Unpleasant 
effects have not been noticed. — Deutsche 
Medic. Wochensch., No. 30, 1891. 



108 



Periscope. 



Vol. lxvii 



periscope. 



THERAPEUTICS. 



THE DRY POULTICE IN THE TREAT- 
MENT OF EPIDIDYMITIS. 

In the Journal of Cutaneous and Gen- 
ito- Urinary Diseases, Dr. George Emer- 
son Brewer reports the successful treatment 
of a number of cases of epididymitis by 
the " dry poultice." This name is given 
to a dressing of cotton wool applied thickly 
over the inflamed portion of the organ 
and extending on to the healthy skin. 
This is covered with thin rubber tissue 
held in place by a snugly applied gauze 
bandage and the whole placed in a suitable 
suspensory. Pains rapidly subside, the 
inflammation disappears, and the organ re- 
turns to its healthy state. 



TRANSFUSION OF SALT SOLUTION INTO 
PERITONEAL CAVITY IN COLLAPSE. 

Johnson-Alloway (Montreal Med. Jour., 
February, 1892) removed the ovaries of a 
woman, aged 42. They were non-adher- 
ent, nodular, and about the size and shape 
of a human kidney, stony hard, and at- 
tached to the uterus by a short pedicle. 
Three gallons of a dark brown limpid fluid 
flowed away from the peritoneal cavity. 
There was evidence of secondary deposit 
in the mesenteric glands and elsewhere. 
Eight hours later the patient was pulse- 
less, restless, sighing, and almost sense- 
less ; the shallow respiration became gasp- 
ing. Johnson-Alloway believed that this 
condition was probably due to the sudden 
withdrawal of a great quantity of fluid, 
which had removed firm and constant pres- 
sure from the. heart and large abdominal 
vessels. He accordingly transfused about 
three quarts of sterilized salt solution 
(tempereture 110°) into the abdominal 
cavity through the glass drainage tube in- 
serted at the operation. The patient im- 
mediately began to scream and vomit vio- 
lently. The tube was removed, and the 
opening closed by firm packs of cotton- 
wool. In about five minutes the radial 
pulse became full. Some hours later the 
abdomen was as flat as when the patient 
left the operating table. The highest 
temperature (second day) was 101.5°. 
The patient left the hospital within four 
weeks. On account of the rapidity of its 



action peritoneal transfusion is preferable 
to hypodermic injections or enemata of 
salt solution. — Brit. Med. Jour. 



PILOCARPINE IN THE STATUS EPILEP- 
TICUS. 

Dr. Kernig (La Semaine medicate, No. 
11, 1892), was called to a case of a young 
girl who was suffering from status epilep- 
ticus. A subcutaneous injection of two 
centigrammes (one-third of a grain) of the 
hydrochlorate of pilocarpine produced co- 
pious perspiration, followed by complete 
and definite arrest of the convulsions. In 
about an hour oedema of the lungs appar- 
ently threatened, together with collapse. 
Fortunately, these disquieting symptoms 
disappeared,, the pulse rose in force and 
frequency, and the patient fell into a calm 
and reparative sleep. 



THERAPEUTIC NOTE ON ALOPECIA 
AREATA. 

Bulkley (Journal of Cutaneous and 
Genito- Urinary Diseases, February, 1892) 
claims for the treatment reported in this 
paper greater success than other methods 
have attained in his hands. It is the 
very thorough application of a 95 per cent, 
solution of carbolic acid to the bald areas. 
He makes a small cotton- wool swab, dips it 
in the acid and lightly paints the affected 
spot, afterwards gently and firmly rubbing 
it in for some seconds. The skin is whit- 
ened, in a day or two becomes slightly in- 
flamed, and within a week or ten days 
sheds its epidermal layer. The process 
may be repeated in two or three weeks; 
and has never given rise to accident — such 
as blistering. No larger area than two or 
three square inches should be attacked at 
a sitting. 



THE DISADVANTAGES OF HOT-WATER 
BOTTLES. 

The custom which so largely prevails 
mainly among ladies of using hot- water 
bottles in bed for the purpose of warming 
their feet, time-honored as it is, cannot 
after all be said to have had much to com- 
mend it. Indeed, there is a good deal 
more which can be urged against it than 
can be said in its favor. Ladies who re- 
sort to the habit, for habit it soon becomes 
in the majority of instances, suffer from 
cold feet, a condition which it is needless 



July 16, 1892. 



Periscope. 



109 



to say does not particularly conduce to the 
wooing of sleep. But cold feet is a symp- 
tom which should not be left to be dealt 
with at the end of the day ; on the con- 
trary, those in whom it occurs should bear 
in mind that in ordinary health the proper 
remedy for this condition is exercise. 
Nothing tends more to cause " cold feet " 
than sitting about the house all day, or 
reducing the daily exercise to a minimum 
amount, either on account of laziness or 
feebleness of will-power for exertion. Some 
persons console themselves with the reflec- 
tion that they were born with cold feet, 
and on these grounds hold that it was al- 
ways intended that they should warm them 
by artificial means, thus ignoring the nec- 
cessity which exists for exercise. Hot bot- 
tles, too, used in this way become a fertile 
source of chilblains, and, moreover, are 
not devoid of danger. We heard the other 
day of two cases in which the ladies using 
them were seriously scalded by the cork of 
the earthenware bottle containing the boil- 
ing water suddenly popping out. This 
brings us to the consideration of whether 
hot bottles should be used at all, and we 
think the answer should be in the negative. 
The best way of warming cold feet at night 
is to clothe them with warm woolen socks 
or stockings, which may be slept in; By 
this means the temperature of the feet is 
gradually raised, and is equably main- 
tained throughout the night without 
trouble or risk. Another useful plan is to 
raise the feet on a pillow about two inches 
above the knee, so as to facilitate the re- 
turn of the blood through the veins of the 
limbs. — Med. Press. 



ANTIPYRINE. 

M. B. Martin, in U Union Medicate, 
Nos. 125, p. 565; 126, p. 577; 128, p. 
601, adds much to the statements of the 
uses of this drug as found in the treatises 
on therapeutics, believing that its antipyr- 
etic properties have over-shadowed others 
equally valuable. It is useful in haemorrh- 
age, in that it locally will contract blood- 
vessels, and, indeed, it is an antiseptic. 
During operations a one-to-twenty, in 
epistaxis one-to-five, in coryza one-to- thirty 
solutions are used. It is valuable in laryn- 
geal affections (catarrhs, stridulous laryn- 
gitis), asthma, broncho-pneumonia, pleu- 
ritic effusions, when given internally. As 
an anti-galactogogue, ten to twenty grains, 



several times repeated; for incontinence of 
urine (should be giving at 9 or 10 P. M.), 
for diabetes insipidus and true diabetes 
(up to a drachm daily) ; for uterine cancer 
(Cheron) ; and in dysemenorrhoea it relieves 
pain. Even the pains of labor are miti- 
gated. Exophthalmic goitre, nocturnal 
pollutions, pains of tubercular meningitis, 
hemeralopia, asthma, either essential or 
of cardiac origin, distress of aortic aneur- 
ism, trigger-finger (subcutaneous injection) 
— all have been benefited ; infantile diarr- 
hoeas (Saint- Philippe) ; with cocaine in 
obstinate vomiting (Struver). Some der- 
matoses, as urticaria, erythema nodosum, 
senile pruritus, and other conditions, where 
exceptional benefit has been obtained, com- 
plete the somewhat extensive list. The 
paper closes with a statement of the acci- 
dents that may be caused by this remedy. 



ACONITE FOR SCORPION STING. 

A correspondent from Durango, Mexico, 
says that formerly about one half of the 
children in the city died from the sting of 
the scorpion, but now nearly all the lives 
are saved, if taken in time, by the use of 
the strong tincture of aconite, of which 5 
or 6 drops are put in a tumbler half full 
of water, and a teaspoonful given at fre- 
quent intervals. — Ex. 



ALKALIES FOR THE INFLUENZA. 

Based on personal experience, Crerar. 
in a paper read before a branch of the 
British Medical Association, fervently 
recommends potassium bicarbonate as an 
unfailing remedy for the cure of influenza. 
The doses administered by him being 30 
grains every two or three hours. The ad- 
vantages of this treatment are summed 
up by the author as follows: "1. If used 
before the attack, .it prevents the disease. 
2. It destroys the power of the disease 
within twenty- four hours, generally with- 
in four or six hours. 3. The strength is 
conserved, and the convalescence is short 
and satisfactory. 4. Sequela? are con- 
spicuous by their absence. 5. The 
death rate is reduced to a minimum. I 
have not had any death in more than one 
thousand cases. 6. It has more power 
over influenza than I have ever seen ex- 
erted by any method of treatment over 
any other disease, and I have had an ex- 
tensive practice for upward of a quarter 



110 



Periscope. 



Vol. lxvii 



of a century. 7. If adopted by the whole 
prof ession, it would make influenza non-ex- 
istent in one week. 8. It rests upon a 
sound scientific foundation/' The last 
two propositions certainly are very sangu- 
incal and rather startling. 



A NEW ANTI-RHEUMATIC. 

Salophene is a derivative. It is obtained 
by treating para-nitrophenol with salicylic 
acid, reducing the nitrophenol by means 
of zinc and hydrochloric acid into an amide, 
and acting upon this with acetic acid. 
Salophene contains about 50 per cent, of 
salicylic acid, and exists in the form of 
thin scales, tasteless, inodorous, and with 
a neutral reaction. It is almost insoluble 
in cold water, and only slightly so when 
warmed. Upon the addition, however, of 
an alkali it readily dissolves. It is very 
soluble in alcohol and ether. It burns 
with a smoky flame, leaving no residue. 
In the stomach salophene breaks up into 
salicylic acid and acetyl para-amido-phenol. 
These substances are excreted by the kid- 
ney, and can be found in the urine. Sal- 
ophene, owing to the presence of amido- 
phenol, is less poisonous than salol. Ac- 
cording to Guttmann, it is a valuable rem- 
edy in articular rheumatism, given in doses 
of from four to six grammes a day in pill 
or in the form of compressed tablets. 



MEDICINE. 



RECURRENCE OF CARCINOMA OF THE 
BREAST 

Dennis {Medical Record, February 27, 
1892), in reviewing the conditions that 
favor the return of carcinoma in the breast, 
says, twenty-five per cent, of the cases 
operated upon fail to recur. The recur- 
rence is influenced by the following con- 
ditions : 

(1) By the period of time from the ap- 
pearance of the growth to the time of 
operation, and places the average time at 
six months, because at this time little or 
no infection of the neighboring lymphatic 
glands has taken place. 

(2) By the extent to which infiltration 
has taken place. 

(3) By the radical character of the 
operation. The extensive operation is 
suggested from, the fact that Kiister had 



examined the glands removed in 117 cases 
of cancer of the breast, and only two cases 
failed to show no invasion. 

(4) By the histological character of the 
carcinoma itself. Tumors showing struct- 
ures departing but slightly from the nor- 
mal are favorable cases, and the more em- 
bryonic the structure the greater the liabil- 
ity to recurrence. 

(5) By the appearance simultaneously 
of carcinoma in both breasts. This con- 
dition, however, exists only in five per 
cent, of the cases. 

(6) By the personal factors of the indi- 
vidual, such as age, sex, marriage, traum- 
atism, race, etc. 

The locality of the carcinoma has a 
marked influence on the recurrence after 
removal. 

More whites die from carcinoma than 
blacks. — Univ. Med. Mag. 



THE PROPER COURSE TO PURSUE WHEN 
A WOMAN WITH SYPHILIS COMES TO 
CONSULT YOU. 

Professor Fournier has just given in one 
of his remarkable lessons the line of action 
to follow when consulted by a syphilitic 
woman. This varies with the social status 
of the patient. If irreguliere, that is to 
say a woman who is kept or a prostitute 
she must be told at once the nature of her 
ailment so as to put her on her guard 
against the danger of infecting others if 
she persists in maintaining relations with 
them. If on the contrary it is a married 
woman the line of conduct is much more 
delicate. To declare rudely that she is 
affected with syphilis is to risk, if the hus- 
band is the culpable one, causing domestic 
trouble, and separation in the family. If 
one simply gives a prescription without 
saying anything, this usually amounts to 
nothing for she does not fail to instruct 
herself upon the real nature of the drugs 
employed and thus learns the truth. The- 
oretically it is better to place the burden 
on the husband of keeping from the wife 
so far as is possible the nature of the dis- 
ease which she has received from him. 
The husband must thus be taken into the 
case and entrusted with the direction of 
the care to be taken and the carrying out 
of the treatment. For this reason Prof- 
essor Fournier does not advise giving the 
patient at the first visit a prescription 
which could awaken suspicion. A local 



July 16, 1892. 



Periscope, 



111 



treatment without mercury should suffice, 
the patient must be told that there are cer- 
tain points in the case which do not ap- 
pear quite clear, and for which reason a 
conversation with the husband will be nec- 
esary, or that there are certain things you 
wish to recommend to the husband, and 
ask to have him sent to see you. If the 
woman is innocent, that is to say if she 
has had relations with her husband alone, 
she will readily comply with your request. 
From this time on you have only to come 
to an understanding with the husband 
keeping as much as possible from the know- 
ledge of the wife the real nature of her 
complaint. However too much secrecy 
cannot be expected, for after a certain per- 
iod of this prolonged and mysterious med- 
ication the woman begins to suspect the 
truth, but the object has already been at- 
tained, scenes of violence have been avoided 
which in the commencement would have 
been precipitated by a sudden discovery of 
the true nature of the disease and usually 
regrettable separations and divorces are 
avoided. But to act as we have suggested 
we must be quite sure of our premises. 
We must be assured that it is from the 
husband alone and not from some other 
that the contagion has come for in the 
opposite case it would be the same as say- 
ing to the husband "your wife has syph- 
ilis and as you haven't it, she must have 
contracted it from some one else." So as 
not to commit such a blunder care must 
be taken in speaking to the husband before 
having the full assent of the wife. If she 
is innocent she will have no reason to op- 
pose the conference, if she is guilty, that 
is to say if she has had relations with other 
persons she will without doubt take you 
at once into her confidence. 



SUPPURATION DUE TO PNEUMOCOCCAL 

R. Condamin {Lyon Med., February 7th, 
1892) records a case of multiple suppura- 
tion, consecutive to a suppurative otitis, 
which presented characters different from 
those usually observed. The ear mischief 
developed suddenly during the course of 
influenza, and rapidly culminated in per- 
foration of the tympanum, having been 
preceded by severe sore throat. Two days 
later the patient's temperature was high, 
and he had several rigors. An abscess de- 
veloped on the dorsum of his left hand, 



which was opened two days afterwards. 
From this time a series of abscesses in diff- 
erent parts of the body, all subcutaneous 
and running a rapid course, developed. 
From fifteen to eighteen at least of these 
were observed, and in each case cultiva- 
tions from them revealed the pneumococ- 
cus of Fraenkel in a state of purity. The 
common character of all these abscesses 
was their quiet development, without acute 
pain — in fact, they behaved after the man- 
ner of "cold" abscesses. The pus was 
very thick, yellow, and odorless; there 
was little tendency towards diffusion, each 
collection tending rather to become 
encysted. The rapidity of the disappear- 
ance of each after being opened by the 
thermo-cautery was most striking. — Brit. 
Med Jour. 



SLOW PULSE. 

Among the causes of slow pulse, Dr. D. 
W. Prentiss enumerates the following, say- 
ing that the causes which produce slow 
pulse may be classified as follows : 

1. Diseases or injuries to the nerve cen- 
ters, producing either irritation of the 
pneumogastric or paralysis of the sympa- 
thetic (accelerator) nerves of the heart. 

2. Diseases or injury of the pneumogas- 
tric nerve, increasing its irritability. 

3. Disease or injury of the sympathetic 
nerves of the heart, paralyzing them. 

4. Disease of cardiac ganglia, by which 
the influence of pneumogastric nerve pre- 
ponderates. 

5. Disease of the heart muscle (degen- 
eration), whereby it fails to respond to the 
normal stimulus. 

6. The actions of poisons, as lead or 
tobacco, either on nerve endings or cen- 
ters. The poison generated in salt fish. 

Also the poison of certain febrile 
diseases, algid pernicious fever. 

Another possibility is malarial poison- 
ing. — St. Louis Medical and Surgical 
Journal. 



CYSTIC DISEASE OF THE KIDNEY. 

After reporting such a case recognized 
during life, Stiller (Berl. hlin. Woch., 
March 7th, 1892) discusses the diagnosis 
of this affection. Of the first importance 
is the recognition of a tumor of renal ori- 
gin. This tumor appears clinically to be 
a solid one. Owing to the considerable 



112 



Periscope. 



Vol. lxvii 



stretching of the capsule over the cysts no 
fluctuation is obtained; on the other hand 
if the cysts are insufficiently stretched, no 
tumor may be felt. Cysts in the liver not 
infrequently co-exist (in 18 out of Le jars' 
62 cases). Fluctuation is not recognised 
in them even when un evenness of the liver 
surface can be made out. The age of the 
patient and the behavior of the disease is 
against carcinoma. The long duration of 
the disease almost without symptoms is 
against suppurating kidney such as is 
found in case of calculus, tubercle etc. 
Hydro- and pyo-nephrosis, or hydatid of 
the kidney, yield fluctuation. The sudden 
onset of uraemia and anuria in a patient 
previously without renal symptoms and 
who has a renal tumor, is in favor of cystic 
disease. A paranephritis may occur owing 
to rupture of the renal tumor. The fact 
of the tumor being bilateral is in favor of 
this disease, but clinically this is not 
usually recognized, although at the necropsy 
both kidneys are much more frequently 
found to be affected. The urine is usually 
abundant and limpid, with little albumin. 
The character of the urine is however only 
of value in the presence of other signs of 
the disease. The diagnosis is important, 
for among other things, extirpation of the 
kidney is contra-indicated, because the dis- 
ease though clinically unilateral by far 
most frequently exists on both sides. — 
British Medical Journal. 



NEURASTHENIA AND HYPER-ACIDITY. 

The Medipini sch- Chirurgische Rund- 
schau reviews an article by A. Pfannen- 
still of Stockholm in the Xordisht Med. , 
Ark. , on the connection between the above- 
named two conditions. Neurasthenia and 
nervous dyspepsia are, according to the 
writer, as frequently seen in Sweden as in 
other parts of the world. A valuable 
addition to the setiology of these complaints 
is that all the cases observed by Pfannen- 
still belonged to the working classes, so 
that neurasthenia is certainly not confined 
to the upper classes of society, who are 
most exposed to the excitement of modern 
life. Of both complaints a primary and 
secondary form can be distinguished; but 
the latter, which is merely a symptom of 
other affections, especially hysteria, is 
much the more frequent. Hysteria is 
more often observed in connection with a 



general neurasthenia, in which the func- 
tions of the secreting nerves are always 
disturbed, and we may find in consequence 
hyper-acidity and hyper- secretion, or sub- 
normal acidity, or even an entire absence 
of acid. The hyper-acidity is entirely due 
to an increase of hydrochloric acid. 
Pfannnenstill considers that this Iryper- 
acidity is the result of an increase in 
the quantity of the gastric juice, 
and not merely of the hydrochloric acid, and 
that there is no decrease in the power of 
absolution. Increased secretion of gastric 
juice is probably the source of hyper- acid- 
ity in other affections of the stomach, and 
the reverse is probably equally true. — 
La.ncet. 



SO-CALLED GONORRHEAL CYSTITIS. 

Du Mesnil ( Yirchovis Archiv, Bd. 
exxvi., Heft 3) proves that there is no 
specific gonorrheal cystitis, the presence 
of gonococci in urine withdrawn by cathe- 
ter being due to the back-flow of pus from 
the urethra into the bladder. Moreover, 
these organisms do not cause decomposi- 
tion of the urine, so that their occurrence 
in an ammoniacal specimen does not imply 
that they were the cause of the change. 
It is probable that the activity of the cocci 
is hindered, if not entirely destroyed, by 
the urine. 



CONTRIBUTION TO THE DIAGNOSIS OF 
TUBERCULAR MENINGITIS. 

A well-built and well-nourished man of 
40 became comatose at the moment of 
entering the hospital on foot, and so re- 
mained until death, two days later. There 
was rigidity of neck and spine and total 
absence of reflex irritability with the ex- 
ception of the knee reflex. Pulse 80, R. 
32, T. 99°. A diagnosis of meningitis 
was made. On further examination a 
moderate empyema of the right side was 
found. The pus was found to consist of 
fat globules almost entirely. As F. has 
pointed out, this is of itself almost patho- 
gnomic of a tubercular empyema, even with- 
out the demonstration of tubercle bacilli. 
Cultures demonstrated the absence of 
pyogenic germs. Autopsy showed a most 
extensive tubercular meningitis, both 
miliary and solitary nodules being ex- 
tremely abundant. Tubercular foci were 
found in both lungs and supra-renal cap- 



July 16, 1892. 



Periscope. 



113 



SENSORY AND VASO MOTOR DISTURB- 
ANCE IN FACIAL PARALYSIS 

' ' Dr. Frankl Bochwart, in an investi- 
gation into the conditions present in 
twenty cases of facial paralysis, found that 
in three there were disturbances of sensa- 
tion and of the vaso-motor functions, in 
five of sensory functions only, and in two 
of vaso-motor only. The sensibility was 
only affected to a very slight degree, and 
sometimes the mucous membrane on the 
tongue and inside of the cheek was 
affected, and sometimes it was not. Oc- 
casionally also taste was affected. These 
sensory phenomena disappeared much 
earlier than the paralysis, but in one ease 
in which the paralysis persisted there was 
diminished sensibility even after several 
years. The conclusion sought to be drawn 
from these facts is that the facial nerve in 
man contains some sensory and vaso-motor 
fibers ; but of course it would first have to 
shown that the fibers of the fifth nerve had 
not also suffered when the facial nerve be- 
came affected." — Lancet. 



HEPATITIS PARENCHYMATOSA BE- 
NIGNA. 

S. Tama draws attention (Nederlandsch 
Tyclschrift v. Geneeskunde, November 
14th, 1891) by a series of cases to a well- 
defined form of parenchymatous inflam- 
matory affection of the liver, which as a 
rule runs a favorable course. Talma re- 
gards the hepatic symptoms as secondary 
to an intestinal lesion, the liver being in- 
fected by way of the portal or lymphatic 
system, the latter being the more likely' 
path. The affection may occur at any 
age; its onset is always marked by severe 
vomiting, accompanied either by constipa- 
tion or diarrhoea, and in the course of a 
few days, varying from one to five, hepatic 
enlargement and tenderness are developed, 
respiration becomes purely thoracic, and 
the symptoms increase with or without a 
rise of temperature (in the severe cases 
the temperature rose to 104° F. in two, 
and to 102° in two other of the recorded 
cases), and the patient becomes extremly 
weak. The diarrhoea and vomiting cease 
in a few days, the urine is usually dark 
colored, and may contain a variable quan- 
tity of bile pigment, and there may or 
may not be slight jaundice. The hepatic 
enlargement is general, though circum- 
scribed enlargements or bosses may oc- 



casionally be detected on the anterior sur- 
face, which may be as large as a hen's egg; 
their presence may mislead the medical at- 
tendant into the diagnosis of cancer or 
even abscess of the liver. Jaundice is 
seldom present, biliary obstruction or sup- 
pression is rare, and ascites has never 
been observed. The spleen is always en- 
larged, but diminishes in size as the pa- 
tient improves. The symptoms in the less 
acute cases gradually disappear in about 
ten days or a fortnight, and recovery is 
generally speedy and uninterrupted. He- 
patic nodules were found in two cases. 
Death resulted in two of the recorded 
cases. In one of these (a child aged 8) 
the spleen was post mortem found to be en- 
larged and firm in density the mesenteric 
glands and the portal and hepatic lymph 
glands were enlarged ; there were no signs 
of recent or old peritonitis. The liver was 
much enlarged and very firm to the touch 
(weight 3,000 grammes). On the upper 
surface nodules were to be seen, regular in 
outline, with broad bases rising gradually 
from and merging into the surrounding 
hepatic tissue ; on section there appeared 
to be no abnormality either in the liver or 
nodules, which latter were of the same 
density as the surrounding structures. 
Microscopical examination revealed an ap- 
parent increase in the quantity of the in- 
ter- and intra-lobular connective tissue; 
the liver cells appeared normal, and care- 
ful investigation of numerous sections dis- 
played no further abnormalities. — Brit. 
Med. Jour. 

PYREXIA AND ANTIPYREXIA, NERVOUS 
AND ARTIFICIAL. 

Eichter, in the Brit. Med. Journal 
Supp.(insm.g. Diss. Breslau, 1891), gives 
an account of some experiments made by 
him on pyrexia and antipyrexia. He first 
of all discusses the mechanisms by which 
the temperature can be lowered and con- 
cludes, as a result of calorimetrical exper- 
iments upon animals in which fever had 
been artificially induced by the injection 
of infusion of hay, that fever consists in a 
shifting of the heat-regulation mechanism. 
He therefore adopts Filehne's theory of 
fever. The difference between a nerve 
temperature and fever is next discussed 
and the author does not believe that there 
is in the brain auy heat center, damage of 
which can cause fever. He regards the 
pyrexia which may be brought about by 



114 



Periscope. 



Vol. lxvii 



damage to the corpus striatum,, as quite 
distinct from fever, being only a tempo- 
rary disturbance of the heat-regulating 
mechanism. 



SURGERY. 



CASE OF TUMOR OF THE PONS. 

Dr. P. Watson Williams (Bristol Med- 
ico- Chirurgical Journal, Sept., '91.) A 
boy, aged six years, slightly hydrocephalic 
had for a time been observed to be growing 
tiresome and fretful. Occasionally he 
would tumble about and fall forwards, or 
go around like a toy, and then fall. Sub- 
sequent examination showed the face drawn 
to the right, internal strabismus; pupils 
large and inactive ; left optic disc blurred, 
and gait unsteady. These symptoms be- 
came more marked. The left leg at times 
dragged, and later became partially paral- 
yzed. Weakness and twitching of right 
facial muscles appeared and paralysis of 
the right sixth nerve. His irritability in- 
creased and there was a steady failure in 
strength. Vomiting only occurred twice. 
Then followed weakness of left arm, and 
later paralysis, dribbling, exaggerated left 
patella, tendon, reflex, and finally death 
from exhaustion. On autopsy the whole 
of the pons was found involved in new 
growth, being much swollen on its anterior 
surface and bulging above in the fourth 
ventricle. Both crura cerebri were like- 
wise enlarged by the extension of the 
growth and the nerves in relation with the 
pons distorted and compressed. The 
third nerves of both sides were flattened 
and displaced, and the sixth nerves wound 
round the bulging posterior border of the 
tumor, especially that on the right side. 
The tumor proved to be a typical glioma. 



OPERATIVE TREATMENT FOR RAPID 
CURE OF DACRYOCYSTITIS. 

G-uaila's (Centralblatt fur praktische 
Augenheilkunde, January, 1892) operation 
is performed in the following manner : The 
patient sits on a chair with his head slightly 
bowed forward, and held in this position 
by an assistant; the sac is then incised 
from the outside, and if there is much 
bulging: of the skin, a small oval piece is 
removed, together with the fistula, if one 
should be present. The blood does not 
get into the patient's throat, as happens 
when the ordinary recumbent posture is 
adopted. One then scrapes out the entire 



inside of the dilated tear sac, being espec- 
ially careful to remove any diseased bone 
met with, and having mopped out the 
cavity very freely with a solution of subli- 
mate of 1 in 5,000, a bone cannula (to be 
described below) is inserted and the wound 
stitched up. The cannula is certainly a 
novel feature of this operation; it is made 
by decalcifying with hydrochloric acid, 5 
per cent. , the bones composing the poste- 
rior limbs of large toads, divided into the 
proper lengths, and hardening and pre- 
serving them in a mixture of alcohol and 
sublimate. The knob-like end of the bone 
at the joint prevents the cannula slipping 
into the nose too far. This procedure has 
given excellent and apparently permanent 
results in the 314 cases the author has used 
it in. 



REMARKS OX THE TREATMENT OF 
TRACHOMA BY THE EXPRESSION 
OF THE MORBID SUBSTANCE 
WITH A ROLLER FORCEPS, 
BASED ON A SERIES OF 
114 CASES. 

Dr. H. Knapp, (Archives of Ophthal- 
mology, Vol. xxi, No. 1.) refers to the 
method for the ordinary treatment of 
trachoma as being unsatisfactory and 
tedious. He gives a w r ood-cut of his roller 
forceps and describes his method of using 
it. 

Of the 114 cases treated there were 16 
cases of follicular catarrh, 64 cases of fol- 
licular trachoma, 22 cases of diffuse 
trachoma, 10 of cicatricial trachoma, and 
2 cases of horny summer granulations. 

Of the 16 cases of follicular catarrh, 
• fifteen were cured. Fifty-four of the cases 
of follicular trachoma were cured, and of 
eight no record was given, but a cure was 
believed to have occurred. Of the 22 
cases of diffuse trachoma, seventeen was 
cured, three did not report after treat- 
ment, one had a relapse, one had an at- 
tack of acute conjunctivitis six months 
afterwards, but no return of the granula- 
tions. Knapp states in reference to his 
forceps : ' ' The new^er instruments have 
conical pivots which dip into correspond- 
ing depressions. Tiemann & Co., pro- 
posed also to make an instrument with 
longer limbs of the stirrup and a set screw 
to remove and cleanze the pivots and 
sockets. At my suggestion they made the 
branches a little longer somewhat elastic so 
that the roller can be removed and re- 
inserted." 



July 16, 1892. 



Periscope. 



115 



sules, though no symptoms of Addison's 
disease were present. This case shows the 
diagnostic importance of a vseteriological 
and microscopic examination of empyem- 
atous matter. — Prof. Prmnkel, Berl. 
Klin. Wochensch. 



OBSTETRICS. 



PERINEORRHAPHY DURING PREG- 
NANCY. 

Weil (Prager med. Wochenschnft, 1892, 
No. 11) reports an interesting case of lac- 
eration involving the sphincter and recto- 
vaginal septum, in which he operated in 
the fifth month of pregnancy, the patient 
being delivered at term without injury to 
the perineum. He regards the operation 
as justifiable during pregnancy when the 
patient is rapidly losing her strength from 
diarrhoea, so that abortion is imminent, 
and suffers severely from the loss of perineal 
support. The danger of infection during 
labor, by reason of the communication be- 
tween the rectum and the vagina, is to be 
borne in mind. Care during the delivery 
of the head, with the performance of epis- 
iotomy, ought to prevent a second lacera- 
tion. — Amer. Jour. Med. Sci. 



TREATMENT OF ASPHYXIA IN NEW- 
BORN CHILDREN. 

W. E.Forest (iY. Y. Med. Pec, April 
9th, 1892) objects to the Schultz method of 
artificial respiration in infants (supplement 
February 28th, 1891), that is too violent, 
and that it must lead to great chilling of 
the surface, which may be sufficient to 
determine the death of the child. He 
suggests the following method: — The 
child is laid for an instant on its face, with 
the head and thorax lower than the pelvis, 
and quick but gentle pressure is made on 
the back ; this is to expel fluids which may 
have been drawn into the air passages. 
The child is then placed in the sitting pos- 
ture in a pail containing warm water in 
sufficient quantity (about 6 or 8 inches) to 
rise a little above the level of the heart. 
The water should be as hot as can be borne 
comfortably by the operator's hand. The 
left hand grasps the wrists with the palms 
outwards, the right hand supports the 
back, the head resting between the thumb 
and fore-finger. The thorax is placed 



in the inspiratory posture by carrying the 
child's hand upwards until it is suspended 
by the arms, the buttocks just raised 
from the bottom of the pail. Forest con- 
tends that in severe cases, in which alone 
artificial respiration is really required, this 
will not be sufficient to cause air to enter 
the lungs since the air cells have never 
been distended, and cannot be distended 
merely by placing the chest in the inspir- 
atory position ; his method, he maintains, 
enlarges the thoracic diameters to their 
maximum, and should be combined with 
direct insufflation. When the arms are 
raised the head falls backwards, and in 
this position, he says, the ceophagus is 
closed; the operator blows into the child's 
mouth while still holding it in this posi- 
tion, and so completes inspiration ; expira- 
tion is effected by . lowering the child's 
arms until the left hand of the operator 
rests against the front of the child's thorax ; 
its body is then doubled forward, and gen- 
tly compressed between the two hands of 
the operator. The main advantages claim- 
ed for the method are that it is gentle and 
effectual, but especially that it provides 
for maintaining the body- temperature, 
and so favors the re-establishment or 
maintenance of the circulation. — Brit. 
Med. Jour. 



GYNECOLOGY. 



REMARKS ON THE OPERATION OF 
EXCISION OF THE BREAST AND ITS 
AFTER-TREATMENT. 

G-ould (Lancet, London, 1892, vol. i., 
No. 8) speaks of certain special points con- 
cerning this operation. In the matter of 
the direction of the incision, the author 
states that two considerations only should 
guide the surgeon. The first is imperative 
and has to do with the complete removal 
of the nipple and skin over the tumor, 
when that is malignant. The second is 
to have the cicatrix parallel to the fibres of 
pectoralis major. In most cases both of 
these objects are best attained by the same 
incision — one enclosing an ellipse of skin 
parallel with the anterior fold of die axilla 
when the arm is at a right angle with the 
trunk. It is stated that it is sometimes 
convenient to prolong the incision into the 
axilla, but never necessary, as the axilla 
can be readily reached from any incision 
for amputation of the breast. The writer 



116 



Periscope. 



Vol. lxvii 



has thoroughly cleaned out the axilla in 
two cases of scirrhus of the breast, through 
an elliptical incision over the gland, the 
long axis of which was vertical. 

When the mamma is not the seat of 
malignant growth, it is recommended not 
to invade the axilla, and even in cases of 
sarcoma the axillary glands are not to be 
removed unless affected. In cases of car- 
cinoma, however, the glands should be re- 
moved from the axilla, together with the 
mass of fat in which they are situated. 
The intercosto-humeral nerve should be 
preserved. 

Bleeding vessels are caught with pres- 
sure-forceps as fast as they are cut. At 
the conclusion of the operation the forceps 
are carefully removed. Occasionally one 
or more arteries will require twisting. A 
ligature is never necessary. Sponges are 
used only to dry the wound and are never 
to be rubbed over its surfaces. The less 
they are used the better. 

The wound is to be thoroughly flushed 
with bichloride solution 1 :2000. A con- 
tinuous suture of fine chromicized catgut 
is recommended, each loop being caught 
up — the buttonhole stitch. A drainage- 
tube is not to be employed. The dressing 
should be aseptic and it should secure ac- 
curate apposition of the wound-surfaces. 
The author uses four layers of boric lint to 
lay over the wound, the margins extending 
an inch beyond the wound in all directions, 
This is held in place by strips of plaster 
two inches wide. Over this, gauze or wool 
is applied, and held in place by a roller 
bandage carried around the trunk in an 
ascending figure-of-8. The arm is held to 
the side by means of an ordinary chamber- 
towel. The towel - is folded lengthwise, 
and between the two folds the forearm and 
arm are placed, the hand being just within 
one end. The towel is then fixed in place 
by pins. 

During the first twenty-four hours a 
firm pillow placed under the arm of the 
affected side may relieve the usually dis- 
tressing backache. After the first day the 
patient may be raised to a sitting position 
by pillows or a bed-rest. The dressing 
may be removed on the seventh day, when 
the stitches may be carefully taken out. 
The wound is re-dressed by two layers of 
sublimate gauze, fixed with collodion, and 
over this a light boric lint dressing held 
with the roller bandage. — Amer. Jour. 
Med. Set. 



DEATH AFTER INTRAUTERINE INJECT- 
ION OF PERCHLORIDE OF IRON. 

H. Pletzer (Centraldl, f. Gynak., May 
7th, 1892) publishes the following case 
which occurred in Bonn last winter. A 
woman, aged 32, was admitted on Novem- 
ber 10th, 1891, for retroversion and chronic 
endometritis. In 1881, after contracting 
syphilis from her husband, she had a stroke 
of right hemiplegia, and the right extrem- 
ities retained traces of paralysis when 
admitted. She had borne seven children, 
five macerated or premature; the retain- 
ing two died when about two weeks old. 
On November 11th, 1891, the curette was 
freely used and the uterine cavity was af- 
terwards painted with tincture of iodine ; 
a Hodge's pessary was also applied to re- 
lieve the anteflexion. On November 16th 
and 18th the uterus was washed out with 
a 2 per cent, solution of carbolic acid, 
and iodine once more applied. The period 
began on November 20th and lasted till 
the 26th. The uterus was then treated 
every two days as before. As uterine 
haemorrhage set in, it was thought advis- 
able to inject iron. About ^-drachm of 
the liquor ferri sesquichloratis (which is 
10 per cent, weaker than the liq. ferri 
perchlor. fortior B. P.) was carefully in- 
jected into the uterus after previous syr- 
inging with the carbolic solution. The 
syringe had lateral holes, and free escape 
of the injection was ensured by means of 
a Bozemann catheter. Then the uterus 
was washed out once more with the carbolic 
solution and the patient put to bed. The 
injection of iron caused pain at the time. 
Fifteen minutes later colicky pains set in. 
Pletzer was called back and found the pa- 
tient livid, breathing, stertorously, and 
complaining of severe hypogastric pain. 
In spite of all kind of treatment the patient 
grew worse and died two hours and a quar- 
ter after the beginning of the alarming 
symptoms. An old lesion was detected 
in the left thalamus opticus. Small clots 
were found between the trabecule in the 
right heart, and soft, non-adherent clots 
in the pulmonary veins. A large coagulum 
was discovered in the right internal iliac 
vein. There was a distinct breach of 
surface on the inner wall of the uterus, 
with strong evidence that through it the 
iron had entered the veins. Pletzer refers 
to Cederskj old's similar case, where the 
uterus was in a state of subinvolution. — 
Brit. Med. Jour. 



July 16, 1892. 



Periscope. 



117 



PEDIATRICS. 



INVASION OF THE SUBCUTANEOUS TIS- 
SUE BY THE DIPHTHERIA BACCILUS. 

In three out of four cases of diphtheria 
Spronck (Centralbl. f. allg. Pathol., Jan- 
uary 1, 1892) found the characteristic 
bacillus in the cedematous tissues round 
about the tracheotomy wound. After lay- 
ing open the trachea in rabbits, the author 
inoculated it with the bacillus of diphthe- 
ria, and then closed up the wound. (Ed- 
ema often appeared round about the wound, 
and the same bacillus was found in it. 
Sometimes the oedema was very extensive 
as if a suitable soil had been provided. 
Babbits showing this oedema died more 
rapidly than the others. The invasion of 
these tissues by the bacillus is signalized 
by this oedema. When the trachea is 
opened its movements favor the penetra- 
tion of the micro-organisms, and subse- 
quent cleansing may be insufficient to re- 
move them. The toxalbumin produced 
by this bacillus is more readily absorbed 
from the subcutaneous tissue than from the 
surface of the mucous membrane. The 
author points to the probability that a 
patient's life may be thus endangered, and 
refers to cases where death ensues two or 
three days after tracheotomy, and no suffi- 
cient cause is found at the necropsy.— 
Brit. Med. Jour. 



able emphysema. Four cases are reported- 
In all the treatment consisted of removing 
the growth by means of forceps of a par- 
ticular model. The operation was per- 
formed at several sittings. In all complete 
recovery or great improvement followed. 



ANTIPYRIN IN DIPHTHERIA. 

Vianna (Sem. Med., March 30th, 1892), 
has found that antipyrin has a marked bac- 
tericidal and toxinicidal action on the 
bacillus diphtheriae. He finds, first, that 
addition of the drug to culture media, in 
the proportion of 2^ per cent., renders 
these unsuitable for the nutriment of the 
microbe ; secondly, that when added in the 
same proportion to actively growing cul- 
tures it causes their death within forty- 
eight hours; thirdly, the toxines are also 
destroyed, for cultures treated as above, 
and also filtered cultures, to which anti- 
pyrine is added, prove, much less virulent 
to guinea pigs than the original cultures, 
animals living five to eight, twelve, fif- 
teen, twenty, and twenty-four days, as 
against three days for the control. Vian- 
na, therefore, strongly recommends the 
use of antipyrin as a therapeutic agent in 
diphtheria. — Brit. Med. Jour. 



HYGIENE. 



SYMPTOMS PRODUCED BY ADENOID 
VEGETATION IN YOUNG INFANTS. 

Lubet-Barbon {Mai. de VEnf., Paris, 
1891, Nov., 499.), reports that in a child 
of one month the symptoms presented were 
that it could not breathe while nursing, and 
while nursing was frequently seized with 
attacks of coughing. It did not gain in 
weight, breathed with mouth open and 
had a constant muco-purulent discharge 
from the nostrils. In another case, a 
child aged sixteen months, there were dif- 
ficult respiration, mouth-breathing, dry- 
ness of the lips, the face of violet hue; 
the respiration was noisy, hoarse, frequent, 
such as to closely simulate the respiration 
in a case of croup. The child has never 
been able to take the breast nor nursing- 
bottle, but had been fed from a glass. 
Cough was frequent and often caused vom- 
iting. In another case there was consider- 



DISPOSAL OF SEWAGE. 

The disposal of sewage is a question 
which has been to the fore for a good many 
years in various countries, says Engineer- 
ing, but which, perhaps, nowhere on the 
Continent has been dealt with in a more 
systematic manner than in Germany. In 
Berlin the drains from the houses receive 
both the rain water, and dirty water, the 
dirty water from the kitchen, etc., and 
the contents of the water closets, conduct- 
them to a system of radial sewers, through 
which they, by a natural fall, proceed to 
a dozen various pumping stations within 
the area of the town. From these the 
sewage, through the medium of combined 
force and suction pumps, passes through 
pipes of three feet or still greater diameter 
to the land which the corporation of Berlin 
possesses, and where the sewage is used 
as a fertilizer. The sewage makes its 



118 



Periscope. 



Vol. lxvii 



final exit through a system of conduits so 
arranged that before reaching them it has 
parted with all its manurial power to the 
soil through which it is made to pass. 
The sewage water thus filtered reaches 
the river through the natural fall of the 
conduits in a comparatively purified state. 
The sewage is an exceptionally good man- 
ure, and the yield of grass on those fields 
that receive it is something quite out of 
the common, so that it can be cut some six 
or seven times during one summer. This 
system also seems to answer well as far as 
the sanitary side of the question is con- 
cerned, but still there are a good many 
places which prefer the method by which 
the sewage is collected in large tanks, 
whereby it is possible to benefit larger 
areas by its fertilizing qualities. Frank- 
f ord-on-the-Maine is another German town 
where the sewerage system is very perfect, 
but owing to the excessive cost of land in 
that locality the sewage is not, as in Ber- 
lin, used as manure in the first instance. 
The sewage is purified before being allowed 
to escape into the Maine, and the residue is 
pumped into receptacles from where the 
farmers fetch it. The town of Hanover is 
also about to adopt the sewerage system on 
a larger scale. In Augsburg and Heidel- 
berg the barrel system is used, much more 
satisfactory in the latter than in the 
former town. In Heidelberg the corpora- 
tion itself attends to the emptying of the 
barrels. — Science. 



MICROBICIDE SUBSTANCES OF THE SE- 
RUM AND ORGANS OF WARM-BLOODED 
ANIMALS. 

M. J. De Christmas {Annates de V Inst. 
Pasteur, No. 8, 1891) contributes a paper 
on this subject. Recent experiments 
have brought a large amount of evidence 
against the notion that this microbicide 
power is in any relation to natural im- 
munity. The experiments now described 
seem to show that it is after all a merely 
physical or physico-chemical phenomenon. 
As serum does not long retain its toxicity, 
the following special method has to be 
adapted for demonstrating its microbicide 
power: (1) A tube containing the serum 
is inoculated; (2) a drop of this mixture 
is withdrawn at once and used to inoculate 
a gelatine plate (control) ; (3) at varying 
intervals other plates are made from the 
same tube. Comparison of the numbers 



of colonies appearing in the plates will 
give them an idea of the bactericidal power 
of the serum. Possible sources of error 
in this method may be (a) an irregular 
distribution of the bacilli; (b) unequal 
size of the drops used to inoculate the 
plates. Christmas, working on the lines 
of Metschnikoff, shows also that abrupt 
changes in the density of the surrounding 
medium have an inhibitory effect on mic- 
robes, so that they may even be killed if 
inoculated from a more dense to a less 
dense medium. Taking an anthrax virus 
which has been grown for ten generations 
in serum, and introducing a drop of it into 
each of three tubes containing respectively 
bouillon, sterile distilled water, and boiled 
water, he made a series of plates from 
each in the manner above described. 
Counting the colonies, he found in every 
case that a very apparent microbicide ac- 
tion had taken place. Other experiments 
show that perhaps much of the microbicide 
power of fresh serum is due to the presence 
of dissolved carbonic acid, for, eliminating 
the error from difference of density, and 
using tubes of bouillon and serum through 
which a stream of C0 2 had been passed, 
the author demonstrated that plates made 
from these showed little or no development 
of colonies. In a further series of experi- 
ments he proves that normal serum of 
rabbits, dogs, and horses has of itself little 
microbicide power, at any rate towards the 
following: B. anthracis, B. typhosus, 
B. pyocyaneus, B. diphtherias, St. pyogen- 
es aureus. Quite a different result is ob- 
tained with the albuminous substances 
separated from serum by alcohol, and dis- 
solved in distilled water. This solution 
shows itself very slightly favorable to the 
growth of microbes. Heating or consider- 
able dilution renders it more assimilable, 
but even then microbes will not develop 
well in it. The explanation offered is that 
microbes require, in order that they may 
assimilate albuminous bodies, the presence 
of traces of peptone, and this substance is 
absent from such solutions. Other more 
subtle influences may, however, also be at 
work. In the last part of the paper Christ- 
mas attempts to determine whether the 
albuminoid substances prepared from the 
organs of animals are similarly by them- 
selves unfit for the nutrition of microbes. 
In these experiments he uses the organs 
(1) of normal rabbits, and (2) of rabbits 
rendered immune against anthrax by pre- 



July 16, 1892. 



Periscope. 



119 



vious injection either of the products of 
anthrax grown in an albuminous medium, 
or of a sterilized aqueous extract of the 
organs of rabbits dead of anthrax. To 
prepare his albuminoid liquids he adopts 
the following process. The organs are 
finely minced, and allowed to stand for 
twenty-four hours under glycerine, which 
is then separated and treated with strong 
alcohol. An abundant precipitate is ob- 
tained, which is freed from glycerine by 
alcohol, dried, and dissolved in water, the 
last traces of alcohol being removed by a 
current of warm air. The resulting liquid 
is yellowish, alkaline, becoming turbid 
on boiling, and giving a white flocculent 
precipitate with alcohol. This solution, 
if obtained from a " receptive " animal, 
behaves towards bacilli just as the solution 
of albumins obtained from serum does. 
Addition of a trace of bouillon to this 
made it an excellent nutrient medium. 
If however, the solution were made from 
an animal rendered immune, the result 
was different. In this case the liquid 
would not serve as a nutrient medium, 
even when mixed with two-thirds of its 
volume of bouillon : in fact it possessed 
some antiseptic power. Christmas does 
not state whether it has the power of ren- 
dering animals immune when injected into 
them. He holds, however, that the sub- 
stance is not the same as the vaccinating 
substance contained in the organs of ani- 
mals dead of anthrax. As to what this 
liquid contains which is not present in a 
similar glycerine extract from normal rab- 
bits — whether it be a " defensive proteid " 
or a ferment — the author gives no definite 
evidence. — Brit. Med. Jour. 



VACCINATION LAW IN ITALY. 

A new vaccination law went into effect 
in Italy with the beginning of the year, 
which requires that every child shall be 
vaccinated before it is six months old, and 
again at eight, or at any time whenever 
the sanitary authority deems it necessary 
to promote individual or public safety. 
Those who are not vaccinated and revac- 
cinated according to the requirements of 
the law, are excluded from schools, facto- 
ries, workshops, benevolent institutions, 
etc. Provision is also made for the culti- 
vation and supply of both animal and 
human lymph. 



MEDICAL CHEMISTRY. 



PHYLLANTIN. 

This is the name given by M. Ossow, 
a Russian chemist, to a bitter principle 
extracted from Phyllanthus niuri, an eu- 
phorbiacea from J ava. The new principle 
has the formula C 30 H 37 8 . It crystal- 
lizes in colorless needless which frequently 
form rosettes or fans. It is almost inso- 
luble in water but dissolves freely in alco- 
hol, ether, chloroform, benzene, benzol 
and glacial acetic ether. Its toxicity is 
the most notable thing about phyllantin. 
It is most deadly, but the exact limits 
of its toxicity have not yet been established. 



TESTING DIABETIC URINE. 

Every one familiar with the behavior 
of diabetic urine towards Fehling's solution 
is aware of the fact that in many cases the 
reagent causes a yellowish or greenish-yel- 
low separation (it can hardly be called a 
precipitate), which refuses to settle for a 
long time, and sometimes does not settle 
at all. J. Seegen has recently proposed 
a method ( Wiener klin. Wochenschr., 
Nos. 6-8) by which this difficulty may be 
overcome. It is as follows : 

Upon a filter in a funnel place some 
finely powdered animal charcoal (from 
blood) and pass through it 20 to 40 cc. of 
urine. Pour the filtrate back until it 
comes through colorless. Next wash the 
charcoal with distilled water. The origi- 
nal colorless filtrate and the washings are 
used for the determination of the sugar. 
When the original urine contained only 
about 0.1 to 0.05 per cent, of sugar, the 
reaction appears in the following manner. 
The original unfiltered urine decolorizes 
Fehling's solution and causes, at most, a 
dichroic, greenish -yellow turbidity. The 
decolorized, filtered urine, when" treated 
with Fehling's solution and boiled, devel- 
ops a yellowish turbidity, due to the for- 
mation of cuprous hydroxide. In the 
first wash water the same may still happen, 
but in the second and third a clean pre- 
cipitate of red cuprous oxide is obtained, 
such as is formed in pure aqueous solution 
of sugar. 

For quantitative purposes the method 
is applied as follows : About 50 cc. of the 
urine are poured into a filter half filled 



120 



News and Miscellany. 



Vol. lxvii 



with blood charcoal, and the filtrate pour- 
ed back again until it passes entirely col- 
orless. The charcoal is now washed with 
very small quantities of distilled water, 
the washings united with the filtrate, the 
liquid measured (it is best to bring it to 
the original volume of urine, filtered), 
and a portion then tested in the usual 
manner. The red cuprous oxide will now 
be found to separate in a normal manner. 
There is, however, a loss of sugar, since 
the charcoal retains some of the latter. 
Experiments have shown that this loss 
amounts to about 10 per cent. 



NEWS AND MISCELLANY. 



THE SCALPEL. 

The Scalpel is the title of a new col- 
lege magazine issued by the College of 
Physicians and Surgeons, of Chicago, 111. 



A BIOGRAPHY OF PROF. D. HAYS AGNEW. 

At the request of Mrs. D. Hays Agnew, 
Dr. J. Howe Adams is preparing a bio- 
graphy of her late distinguished husband ; 
in consequence, he is looking for data 
on this subject, and is desirous of obtain- 
ing from all of Dr. Agnew's former friends, 
colleagues, associates, students and ac- 
quaintances all such authentic data as 
relate in any way to his career or character. 
Dr. Agnew^s acquaintance was so vast and 
his life was so actively spent among his 
friends, while his own modesty was so 
marked, that undoubtedly a great many 
incidents, anecdotes, characteristic stories, 
etc., etc., are unknown to his family. 
All material, however insignificant or 
small, will be welcomed, and credit will 
be given to all data which are used. 



VACCINATION IN ITALY. 

The Sanitary Inspector states that a 
new vaccination law went into effect in Italy 
with the beginning of this year, which re- 
quires that every child shall be vaccinated 
before it is six months old, and again at 
eight, or at any time whenever the sani- 
tary authority deems it necessary to pro- 
mote individual or public safety. Those 
who are not vaccinated and revaccinated 
according to the requirements of the law, 
are excluded from schools, factories, work- 



shops, benevolent institutions, etc. Pro- 
vision is also made for the cultivation of 
both animal and human lymph. This has 
a direct interest for people in this country 
in view of the large and constantly increas- 
ing Italian immigration. 



A NEW, SAFE METHOD OF ADMINISTER- 
ING TOXIC MEDICAMENTS. 

The increased knowledge resulting from 
research in the fields of botany, chemistry, 
physiology, pharmacy, and materia 
medica has created a demand on the part 
of the medical profession for the 
essential or active principles of drugs in 
preference to the more cumbersome, less 
definite pharmaceutical preparations which 
custom and authority have so long sanc- 
tioned. 

Not a few alkaloidal principles of drugs 
have been isolated, and are now frequently 
prescribed. The conservative element of 
the profession have, however, in view of 
the toxicity of certain isolated medicinal 
principles, and the acknowledged variety 
of strength and activity of products of 
this character of different manufacture, 
been loath to employ them when indi- 
cated. 

The doses sometimes being fractions of 
a thousandth or hundredth, it is not 
possible for the physician to always bear 
them in mind, and in prescribing he is 
often in doubt as to what constitutes the 
proper therapeutical dose, and what the 
dangerous toxic one. 

Dr. E. Trouette, in a paper read before 
the Paris Academy of Medicine, and pub- 
lished in the Revue de Therapeutique, 
entitled "Duodecimal Doses of Toxic 
Medicaments," proposes a method of ob- 
viating the difficulties hitherto preventing 
the general use of many valuable medici- 
nal principles. The plan he proposes is a 
new method of dosology based on the ra- 
tional division into twelve parts of the 
maximum dose which may be given to an 
adult in twenty-four hours. 

The advantages claimed for this method 
are, first, accidental poisoning need no 
longer be feared. Second, dangerous 
medicaments may from the outset be given 
in efficient dose without the least risk. 

One of our leading pharmaceutical firms 
has prepared diurnules and diurnal tablet 
triturates of a large number of toxic med- 
icaments. 



Vol. I,XVII, No. 4. 
Whole No. 1847. 



JULY 23, 1892 



$5.00 per Annum 
10 Centa a Copy 



A Weekly Journal. 



Established in 1853 by S. W. BUTLER, M. D. 



THE 



MEDICAL AND SURG 
REPORTER 1 



EDWARD T. RE/ CHERT, M. D., Editor, 

Entered as Second-Class matter at Philadelphia P. O. P. O. BOX 843* P' 




CLINICAL LECTURES. 

Dr. Rendu, Paris, France. 
Nuclear Ophthalmoplegia in the Course of Tabes. 121 

C. L. Dana, M. D., New York, N. Y. 
Progressive Muscular Atrophy ; Headache from 
Eye-Strain; Hysterical Vomiting 126 

COMMUNICATIONS. 

D. H. Williams, M. D., Knoxville, Tenn. 

The Treatment of Acute Articular Rheumatism: 
A Clinical Study of Eighty-four Cases with Con- 
firmatory Plea for the Salicyl-alkaline Treatment. 

P. I. Leonard, M. D., St. Joseph, Mo. 
The Circulation in the Brain and Eye with In - 
creased Pressure and Glaucoma 



129 



135 



C. H. Hughes. M. D., St. Louis, Mo. 
Note on the Hysterical Concomitants of Organic 
Disease 138 

CORRESPONDENCE 140 

SELECTED FORMULAE 141 



LEADING ARTICLES. 

The Therapy of Abortion , 143 

Application of Cold in Traumatic Surgery 144 

BOOK REVIEWS 146 

PERISCOPE. 

Therapeutics 146- 

Medicine 154 

Surgery 155 

Obstetrics 157 

Gynecology 157 

Pediatrics 158 

Hygiene 159 

Medical Chemistry 160 

NEWS AND MISCELLANY. 160 



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THE 

MEDICAL AND SURGICAL 
REPORTER. 

No. 1847. PHILADELPHIA, JULY 23, 1892. Vol. LXVII— No. 4. 



Clinical lectures* 



NUCLEAE OPHTHALMOPLEGIA IN 
THE COUESE OE TABES. 

By DE. RENDU, 

PARIS, FRANCE. 

A CLINICAL LECTURE DELIVERED AT THE 
HOPITAL NECKER. 

Gentlemen: — I will to-day refer to you a 
patient who must have certainly attracted 
your attention on going through the wards, 
owing to his curious aspect and the char- 
acteristic appearance of his face. In fact, 
this man is suffering from a double ptosis ; 
his eyes are tightly closed ; he cannot open 
them, and so marked is the condition, that 
it has been necessary to apply a suitable 
bandage in order to keep elevated the up- 
per eye-lids, without which appliance they 
inevitably fall. This paralysis stands by 
itself, so to speak, since the integrity of 
the other peri-orbital muscles is almost ab- 
solute; the movements of the eye-brows, 
those of the frontal, of the orbicularis pal- 
pebrarum, as well as of the other muscles 
of facial expression, are perfectly normal. 

If you raise his eye-lids, you will im- 
mediately discover that on both sides, that 
is, on the right as well as on the left, the 
eye-ball is directed outwardly: in other 
words, there is a marked divergent strab- 
ismus. It is absolutely impossible for the 
patient to put the eye-ball in a normal po- 
sition ; there is a complete paralysis of the 
internal rectus. The upward and down- 
ward movements are likewise impossible to 
execute ; nay, I commit an error in thus 
expressing myself, for the latter movement 
can still be made, its amplitude, however, 
being greatly diminished; and if you make 
a close examination you will see that it is 
accompanied with a certain amount of ro- 



tation of the eye-ball; this is effected by 
the intermediary action of the superior ob- 
lique. In one word, only the muscles sup- 
plied by the oculo-motor nerve are paraly- 
zed, but (and this is an exceedingly impor- 
tant point) this nerve is not completely af- 
fected, since the size of the jmpil remains 
perfectly normal. Contrary to what is 
seen in cases of ptosis, accompanied with 
external strabismus, there is no mydriasis. 
The iris is not paralyzed; it contracts per- 
fectly to light, and you will observe that 
the pupillary orifice contracts or dilates ac- 
cording as an object is placed near or far 
from it. Add to this, finally, that the vis- 
ual acuteness is normal, more so on the 
right side ; on the left (where the ptosis is 
older) it seems that it is not entirely so. 

If we are to investigate the cause of 
these symptoms, we will find that our 
patient has a most interesting history. 
His health had been good up to 1887 ; he 
had previously suffered, in 1865, from in- 
termittent fever, and in 1868 contracted 
syphilis. He was afterwards, at Lyons, 
treated during 3 months for the perfectly 
characterized secondary symptoms of the 
constitutional disorder. After this he did 
not complain of any illness for a period of 
20 years, and he thought that his syphilis 
had been entirely cured, which, I will re- 
peat, was only treated during 3 months. 
The patient became afterwards subject to 
periodical cephalalgias and a slight trouble 
of the kidneys. 

On the month of July, 1887, he went 
to South America, and there was obliged 
to make long rides on horseback. One 
day he was violently thrown from his 
horse, and when he returned to conscious- 
ness was told by his comrades that his left 
eye-ball was directed outwardly, and from 
that moment he continued to suffer from 
diplopia, which, as you see, had a sudden 
onset. At this time he was obliged to 
wear a bandage over the injured eye in 



122 



Clinical Lectures. 



Vol. lxvii 



order to correct his diplopia, his vision 
being then confined to one eye. 

There were, at the same time, other 
symptoms apparently foreign, so to speak, 
to the orbicular trouble : difficult micturi- 
tion, at first slow and then a little painful ; 
gastric derangement, and localized sweat- 
ings on the inferior extremities, accompan- 
ied with a pruriginous eruption over the 
plants of both feet. 

Two months later, in February 1888, 
there appeared a progressive falling of the 
eye-lids, these being kept up only by 
means of the fingers. The patient could 
perceive also that the deviation of the eyes 
was on the increase; that the left eye- 
ball had already turned outwardly com- 
pletely, and that the right one had com- 
menced to exhibit a similar phenomenon. 
After this, he was not, strickly speaking, 
troubled with diplopia, but he had now 
lost binocular vision, and to-day the images 
perceived by him have an inclined form. 
Vision was only distinct in one eye, but at 
this time there had not appeared any 
ptosis of the right side. 

This condition remained stationary 
during a period of 4 years, his general 
health continuing good, with the excep- 
tion of occasional vertigos which he would 
experience especially when subjected to 
sudden drafts of air. He never suffered 
from dizziness nor from loss of conscious- 
ness. Fortunately for him, the ptosis of 
the left side completely destroyed the 
vision of one eye ; by this he could see 
distinctly with the other eye ; and he was 
thus enabled to continue at his trade 
which was that of a peddler. On the 29th 
of February, however, a change for the 
worst occurred. The patient, on attempt- 
ing to bring down an object situated at a 
certain height, raised his head suddenly; 
and he was then attacked by vertigo, fall- 
ing to the ground unconscious. He re- 
mained in this condition for 2 hours; 
when consciousness was regained he com- 
plained of severe pains all over the head, 
the back of the neck and the orbital region ; 
the right eye-lid fell, and it became im- 
possible for him to raise it now. 

It was under these conditions that the 
patient sought our advice. Here is, then, 
an individual who has been attacked in 
succession (and every time in a rapid 
manner) by a double ptosis and paralysis 
of the movements of the eye-ball, move- 
ments which are under the influence of 



the oculo-motor nerve. It remains for us 
now to determine what is the lesion that 
has produced these various symptoms. 

It is hardly possible to believe in that a 
cerebral, peduncular or pontine hsemor- 
rhage has been the origin of such accidents. 
In a case of this nature we would observe 
upon our patient the existence of motor 
and sensory troubles; following the 
haemorrhage or the congestion, there would 
appear a hemiplegia accompanying the 
ptosis, and afterwards a double hemiplegia 
if the lesion were extensive enough to af- 
fect both cerebral peduncles. The symp- 
toms can be dated to 4 years ago; a 
haemorrhage that old, capable of bringing 
about such disorders, would be followed, 
as is the rule, by a descending sclerosis 
characterized by contraction. 

The hypothesis concerning a cerebral 
tumor affecting from the start the origin 
of one of the oculo-motor nerves, then 
that of the opposite side, deserves to be 
discussed with a great deal of care. This 
tumor might have lied upon two distinct 
points. Supposing it to have developed 
over the inter-peduncular region, on the 
level of the superior border of the pons ; it 
could readily be understood how, provided 
it had acquired a sufficiently large size, 
such a tumor would press on the origin 
of the third pair. In such a case, how- 
ever, we would have resulting motor phen- 
omena, and partial tingling of the facial 
nerve, but nothing of the kind is observed 
in our patient. 

Shall we admit, as in a case reported by 
Christ (Deutsch. arch. f. Klin. Mediz. B. 
XLVI, s. 497), the development of a 
tumor on the floor of the fourth ventricle, 
pressing on the nuclei of origin of the 
oculo-motor nerve, which are situated, as 
you know, not far from it? Under this 
hypothesis, the initial symptoms are iden- 
tical with those we have observed in our 
patient ; but their evolution is somewhat 
different. There may be produced, in- 
deed, and quite rapidly, a progressive in- 
vasion of the motor centres of the face 
and neck, there coming on, in a few days, 
a labio-glosso-laryngeal paralysis, accompa- 
nied with ocular trouble, optic neuritis, 
etc. 

Is it a syphilitic gumma with which we 
are dealing? Bearing in mind that our pa- 
tient has, with a certainty, suffered from 
syphilis, this latter opinion may be enter- 
tained; but if we attempt to localize the 



July 23, 1892. 



Clinical Lectures. 



123 



gumma, we come across certain difficulties, 
difficulties which we have pointed out in 
regard to tumors of the pons. 

We can, nevertheless, solely by the an- 
alysis of the symptoms, come to the con- 
clusion that we are dealing with a lesion 
affecting the floor of the fourth ventricle. 
Indeed, the dissociation of the present 
paralytic phenomena, the integrity of the 
pupil, contrasting with the ptosis and the 
paralysis of the ocular muscles supplied by 
the oculo-motor nerve, all this would in- 
cline us to admit the existence, not of a 
lesion of the nerve, but of an alteration of 
its nuclei. 

You remember the beautiful researches 
of Hensen and Voelkers (Archiv. f. Oph- 
thalmol. Bd. XXIV, S 1-26) regarding 
the origin of the third pair ; you know that 
the nerve arises in isolated cells or in 
groups of cells, situated at the superior 
portion of the floor of the fourth ventricle, 
along the aqueduct of Sylvius. The fibres 
for the muscles have their origin in the 
nuclei alongside of the aqueduct; those 
for the iris, arise more externally, from 
the lateral portions of the floor. You will 
understand then, how lesions (the nature 
of which .1 have not yet established) of 
those groups of cells nearest the aqueduct 
of Sylvius, can produce motor phenomena 
of the eye-lids and of the eye-ball, without 
at all affecting the pupil. Is not this 
what is observed in our patient? The par- 
alysis of the extrinsic muscles under con- 
trol of the oculo-motor nerve, permits us 
to say that it is not due to a neuritis or to 
pressure upon the nerve ; in this latter in- 
stance we would have a total paralysis. 
In the case under consideration, on the 
contrary, the dissociation of paralytic 
phenomena is the best proof that the les- 
ion is of a centric origin, and that the les- 
ion affects, although not all of them, the 
cells of origin of the oculo-motor fibres. 

What is then the disorder capable of 
producing such symptoms ? Are we deal- 
ing in the present instance with superior 
acute poliencephalitis, a good description 
of which has been furnished us by Wer- 
nicke (Archive f. Psychiatrie, 1889)? 
This is a disease as yet imperfectly known, 
characterized by a rapid destruction of the 
motor centres of the eye. Following the 
rapid invasion of an ophthalmoplegia there 
appear, in a very short time, symptoms of 
staggering, muscular rigidity and phychi- 
cal disorders resembling those of a delirium 



tremens. This disease is ordinarily devel- 
oped under the influence of alcoholism, in 
a rapid manner, and has a sudden termin- 
ation in the course of from three to four 
weeks, or else death is preceded by symp- 
toms of a labio-glosso-laryngeal paralysis. 
From an anatomical point of view, this 
disorder may be absolutely likened to an 
acute myelitis of the anterior horns. Now, 
in our case the development of the affec- 
tion, which has been slow (it has lasted 
four years), and the absence of other 
medullary symptoms suffice for us to ex- 
clude the diagnosis just referred to. 

Progressive atrophy of the medullary 
nuclei or centres may give rise to similar 
symptoms. This malady, whose process 
is the same as that of progressive muscular 
atrophy of the cord is quite rare ; but I 
can cite two well marked examples of it. 
One of these cases is that reported by 
Bernhardt (Berl. Klin. Woch., October, 
1890) : An individual, after an attack of 
nuclear ophthalmoplegia, exhibited symp- 
toms of labio-glosso-laryngeal paralysis, 
and died suddenly ; he did not show a sin- 
gle sign that would lead one to suspect the 
presence of tabes. The other case recorded 
by Wherry (Paragensia with ophthalmo- 
plegia, British Med. Jour., May, 1891) 
occurred in a man who after a sudden 
attack in which he did not suffer from loss 
of consciousness, complained of a bitter 
taste in the mouth, and then of diplopia, 
progressive ophthalmoplegia with deviation 
of the two eye-balls. A knowledge of the 
previous history of the case, led the author 
to admit the existence of a syphilitic lesion 
of the centres of the third pair, situated 
in the neighborhood of the aqueduct of 
Sylvius ; such was corroborated by the fact 
that a complete cure was obtained after a 
course of an iodated treatment. 

This observation presents a marked 
analogy with our case; yet I do not believe 
that we can accept a diagnosis of this kind. 
It is the presence of tabes to which we 
must attribute the eye-symptoms exhibit- 
ed by our patient. Indeed, we have be- 
fore us a tabetic patient, and I will show 
you that such is the case, by bringing to 
your consideration certain details concern- 
ing the pathological history of this indi- 
vidual, details to which I have not, 
purposely, directed your attention before. 
After the first symptoms of ocular paraly- 
sis, in 1888 and 1889, the patient suffered 
from sharp pains in the lower extremities, 



124 



Clinical Lectures. 



Vol. lxvii 



which at first, were only occasional, but 
always of a lancinating character, peculiar 
to them ; at the same time, the patient 
complained of a feeling of constriction 
over the thorax and in the head, and of 
sensory disturbances over the region of the 
trigeminal, such as numbness of the lips, 
loss of buccal and palatine sensibility. 
Micturition became difficult and laborious, 
notwithstanding that there was no stricture 
of the urethra. Finally, at the beginning 
of 1891, his walking became bad, and he 
assures us that his heels were particularly 
weak and had a tendency to draw towards 
one another. 

After the last attack, which was ac- 
companied with loss of consciousness, the 
symptoms became more pronounced. The 
patient could not stand erect, except when, 
by artificial means, he could keep one of 
his eyes open. The signs of Rombert and 
Westphal are now plain, and there are sen- 
sory disturbances, and especially marked, 
a spot of hypersthesia on the right thigh. 

Here, therefore, the diagnosis is evident. 
We are dealing with a case of tabes, which 
manifested itself at first, by an ophthalmo- 
plegia whose character, during four years, 
has been essentially progressive. I will, 
however, call your attention to the fact, 
that this tabes has exhibited a marked 
peculiarity, and the predominence of the 
medullary phenomena, the total absence of 
a special localization, of trophic or articu- 
lar disturbances, distinguish it from other 
varieties of tabes with which we frequently 
meet. 

The existence of oculo-motor paralysis 
in the course of locomotor ataxia, is not, 
moreover, absolutely rare. After the first 
works of Hutchinson, in 1879, a certain 
number of observations have been pub- 
lished. I will recall to your minds the 
quite recent cases reported by Pel (Berl. 
Klin. Woch., 1890), Ziem (Em fall von 
doppelscitiger ophtalmoplegie. Centralbt. 
fur. hervheilhunde, 1887), Blanc (L'Oph- 
talmoplegie nucleaire, Archiv. general, de 
med., 1887), and Dejerine who last year 
exhibited three patients whose condition 
was identical to the one that has been the 
object of this lesson. Ophthalmoplegia 
does not always present the same charac- 
ters ; it may be complete, the iris becom- 
ing implicated ; the muscles of the eye-ball 
may be affected, while the elevator of the 
lid remains intact*. From a clinical point 
of view, it is important to make a distinc- 



tion between two great groups of ophthal- 
moplegia which affects all the extrinsic 
muscles of the eye-ball, and internal oph- 
thalmoplegia in which only the iris becomes 
implicated. The onset of the disorders is 
generally sudden, that is, that of the par- 
alysis the appearance of which indicates a 
permanent trouble, as well as that of sim- 
ple functional disturbances that generally 
get well in a few weeks (Wherry). We 
must not forget, however, that relapses in 
these latter instances are not rare. We 
frequently meet with tabetic patients who 
show signs of ophthalmoplegia at more or 
less prolonged intervals. 

How can we explain this phenomenon ? 
It seems that an identical explanation can- 
not be given in every case. If, as is often 
the case, the ophthalmoplegia is due to 
centric lesion affecting primarily the nuc- 
lear origin of the oculo-motor nerves, com- 
pletely destroying the nerve cells, it may 
also result from a primary alteration of the 
nerve trunks, from a neuritis of the oculo- 
motor nerves. This seems to me the most 
probable explanation that we can offer in 
cases of curable ophthalmoplegia. Neuri- 
tis of this nature comes on, most fre- 
quently, after an attack of an- infectious 
disease during which, as you know, the 
poison has a marked tendency to localize 
itself upon the nervous system. In one of 
my last lectures I had occasion to show 
you a case of double neuritis as a sequela of 
influenza, and I then called your attention 
to the relative benignity of such neuritis, 
corroborated by the fact that in the case, 
a woman, sight was completely recovered 
soon afterwards. 

In tabes, as I have said, slight cures of 
cases of ophthalmoplegia have been ob- 
served (Pel). Is this a sufficient reason to 
completely exclude, in such instances, a 
lesion of the centres, and to attribute the 
symptoms noticed to a neuritis ? I, my- 
self, do not believe in such a hypothesis, 
and it seems to me that up to the present 
time, it lacks evidence. 

Dejerine believes that in order to es- 
tablish a diagnosis between the centric 
and the peripheral origin of the symptoms 
observed, the fact of curability should, 
above all, be taken into consideration. 
Such an opinion, however, is absolutely 
free from criticism. Again, nothing will 
hinder us from admitting that a cell alter- 
ation, sufficiently marked to produce 
paralysis, is not susceptible of cure (a 



July 23, 1892. 



Clinical Lectures. 



125 



complete cure), as in the case of a similar 
lesion of the nerve trunks. Finally, the 
dissociation of the paralytic phenomena is, 
to my mind, a capital proof in favor of 
their centric or nuclear origin. 

What produces this alteration in the 
cells ? It is more than probable that the 
symptoms are due to an acute congestion 
analogous to that which causes the lan- 
cinating pains; this hypothesis is in accord 
with the other inflammatory phenomena 
which accompany the ophthalmoplegia of 
tabetic patients : cephalagia, vertigo, pain 
in the back of the neck, and in the eye ; it 
explains, in one word, the ordinarily 
sudden onset of the symptoms. This 
congestion, if persistent or repeated may, 
later, give rise to the progressive develop- 
ment of an ependymal sclerosis, compar- 
able to that of the posterior spinal nerves, 
which may destroy the motor centres. 
These inflammatory outbreaks, occuring 
in the course of tabes, resemble very much 
those which you have seen come on in the 
course of general paralysis which has 
moreover, many other analogies with ta- 
bes ; besides, it is not absolutely exceptional 
to see tabetic patients exhibiting cerebral 
disorders, such as difficulty of speech, 
vertigo, loss of consciousness, symptoms 
all which are similar to those occurring in 
general paralytics. We have at present, 
in one of our wards, a beautiful example 
of a similar association of symptoms which 
cannot be explained, 1 think except by the 
existence of a congestion of the brain. 

On the other hand also, these circula- 
tory disturbances of tabes may be traced 
to a vascular change, thus, Berger {Bull, 
mens. Soc. Biolog., March, 1889) has re- 
ported a tabetic case in which he found 
the existence of an obliterating endoar- 
teritis of the medullary vessels, which ex- 
plained the symptoms observed. Finally, 
it is through the vascular alterations 
produced, that syphilis became the genesis 
of a large number of cases of locomotor 
ataxia. 

In the present case the prognosis of oph- 
thalmoplegia, in seems to me, is exceed- 
ingly serious; the symptoms are of too 
long standing to hope that they will retro- 
cede. I believe that in our patient the 
paralysis will be permanent; in him the 
condition is incurable. On the contrary, 
it does not seem to me that the intregity 
of the sight is so seriously threatened. It 
is true that atrophy of the optic nerve 



comes on soon in the parataxic period of 
tabes or in the slow ataxias, but almost 
never does it coincide with the appearance 
of the ophthalmoplegia. 

The greatest gravity of the prognosis is 
the danger of the medullary symptoms. 
If you admit that the phenomena observed 
in our patient are of a centric origin, and 
if, on the other hand, you will not forget 
that the oculo-motor nuclei are the neigh- 
bors of the circulatory and respiratory 
centres, you can readily understand how a 
more or less pronounced congestive pro- 
cess may bring about the production of 
serious symptoms, and even sudden death, 
as I have had the opportunity to observe 
in one case. Our patient has some diffi- 
culty of deglutition, which seems to show 
that the circulatory disturbances are not 
limited to the motor centres of the eye, 
but that they have a tendency to spread 
over the inferior portion of the fourth ven- 
tricle. The occurrence of such a develop- 
ment ought not to surprise us in the 
ordinarily rapid march of a medullary 
atavia. 

I think that we are authorized in this 
case to give syphilis the preference, re- 
garding the aetiology of the symptoms 
present; the onset of these, to a certain 
point, furnishes us the proof of our asser- 
tion. Indeed, the researches of Fournier 
has shown that 43 per cent, of tabetic 
cases occurring in syphilitic patients, be- 
gin at the brain, and the author concludes 
by saying that the cerebro-medullary form 
of tabes is observed especiallly in those 
syphilitic subjects in whose personal or 
hereditary previous history, moreover, it 
has not been possible to find a sufficient 
reason to explain that especial localization. 

In spite of the probable syphilitic origin 
of this tabetic case, I do not believe that 
the specific treatment can produce an 
amelioration of the symptoms. Again, it 
is unfortunately the rule, in the majority 
of tabetic cases in which syphilis has been 
recognized as the cause, to find that the 
specific treatment is nearly always useless. 
Nevertheless, as this is the only rational 
medication to employ in such instances, I 
will not deprive our patient of it. I will, 
therefore, place him for a time under an 
active antisyphilitic treatment, such as 
mercurial inunctions and iodide of potas- 
sium internally in doses of from four to 
six grammes daily. I will also order re- 
vulsion and sulphur baths ; but I will not 



126 



Clinical Lectures. 



Vol. lxvii 



apply to the temples or the eye-lids, con- 
tinuous or interrupted currents, because 
I believe that in cases of this nature elec- 
tricity does more harm than good. — 
Translated from Le Bulletin Medical, No. 
22, 1892. 



PKOGRESSIVE MUSCULAR ATRO- 
PHY; HEADACHE FROM EYE- 
STRAIN; HYSTERICAL 
VOMITING. 



By C. L. DANA, M. D., 

PROFESSOR OF NERVOUS DISEASES IN THE 
N. Y. POST-GRADUATE MEDICAL SCHOOL. 



Gentlemen : — You have already seen this 
patient once before so that it is not neces- 
sary for me to go into details of his case. 
From the general aspect of the right fore- 
arm you will see that he has progressive 
muscular atrophy. He is a boiler-maker 
by occupation. When I presented him to 
you before, I told you that the affection 
had come on very slowly; that there had 
been first a loss of grip, then atrophy, 
fibrillary contractions and vaso-motor dis- 
turbance, such as sweating. Progressive 
muscular atrophy of this kind is due to a 
degenerative process in the anterior horns 
of the spinal cord ; it was formerly called, 
an inflammation but it is a progressive 
necrotic process, and not an inflammation. 
The plan of treatment which has been 
adopted, consists in injections of gr. 
of nitrate of strychnia daily, and it is my 
usual practice to give it alternately in the 
affected part, and in the back of the neck. 
It is given hypodermically, because expe- 
rience has shown that in a certain propor- 
tion of the cases, the muscular atrophy is 
arrested by this treatment, and it seems 
reasonable to suppose that when a drug is 
administered subcutaneously, it " rushes " 
upon the nervous centres, so to speak, and 
exerts a more powerful effect upon them, 
than when it is slowly absorbed from the 
stomach into the circulatory system, and 
so gradually reaches the nervous centres. 
I frequently also prescribe phosphorus and 
arsenic, as in the following formula : 

T> Potassii arsenit gr. j. 

XV Thomson's solution of phosphorus — oz. iv. 

Misce. Sig.— One teaspoonf ul, gradually increased to 
a tablespoonful, t. i. d. 

In addition to this, these patients should 
have the best of food, and an abundance 
of fresh air, and a moderate amount of 
electricity and massage. In progressive 



muscular atrophy, there is a temptation to 
yield to the solicitations of the patient, 
and do too much. You should pick out 
each muscle and electrify it with the fara- 
dic current, not more than six times at 
each seance, and massage should be carried 
out in the same careful way. Three times 
a week is usually sufficient, and I fre- 
quently alternate the electricity and mass- 
age. 

The other day I saw a most pitiful case 
— a man who had been brought to this 
city from a western town. He had en- 
joyed excellent health up to four years 
ago, but at this time, his feet began to get 
weak, he noticed a steady wasting away of 
his muscles. About one year after this, 
the left leg began to be affected in the 
same way; first, the toe dropped, then the 
foot turned outward a little, then the 
calf began to waste, and after about a 
year and a half, he was unable to walk at 
all, and his two lower limbs were pefectly 
helpless. He then found that when sit- 
ting in a chair, if he leaned forward, he 
could not resume his former position, and 
if he leaned over backward, he would fall; 
in other words, the muscles of the abdo- 
men, and the erector spinse muscles had 
become weakened. The arms were the 
next to become affected. He had during 
this time, consulted a number of physicians, 
and some of them had been much puzzled 
over his case, but all expressed the opinion 
that his condition was incurable. As a 
last resort, he came to this city, a physical 
wreck, although his mind still remained 
keen. After careful electrical and other 
examinations, I made a positive diagnosis 
of chronic poliomyelitis of a progressive 
character, a condition which bears a very 
close relation to progressive muscular 
atrophy. The anterior horn cells in this 
man's spinal cord four years ago began to 
degenerate; first the right leg, then the 
left leg groups, then those of the back be- 
came affected, until now there is scarcely 
any gray matter in the anterior horns. 
So great have been the ravages of the dis- 
ease, that now the prognosis is almost 
hopeless. I expect that there will next 
be some difficulty in speech or deglutition, 
or that he will have a respiratory paralysis 
from involvement of the phrenic nerve. 

We are taught that progressive muscu- 
lar atrophy is a hopelessly progressive dis- 
ease, but this is not true, for there are 
certain types in which the progress of the 



July 23, 1892. 



Clinical Lectures. 



127 



disease can be staid. One observer re- 
ports a series of eleven cases in which, the 
atrophy was checked in eighty per cent, 
of the cases of hypodermic injections of 
nitrate of strychnia. I believe in the 
utility of these injections, and I think in 
addition to this, the "rest cure" should 
be prescribed, and the patient given stim- 
ulants and abundance of good food, par- 
ticularly fatty food. 

HEADACHE FROM EYE-STRAIN. 

This next patient is a plumber by occu- 
pation, and he comes to us with the famil- 
iar story of a pain in the head. He does 
not smoke, drink, or chew, so that we can- 
not attribute his trouble to such vices. 
These pains first began about three months 
ago, and they are usually located in the 
temples, although sometimes they are felt 
in the top of the head. They do not al- 
ways begin at the same time in the day, 
and they are attended by a certain degree 
of mental confusion, but without nausea 
or vomiting, or dizziness. He is not anae- 
mic or dyspeptic. So far as I had time to 
test his vision, it is fairly good. The case 
evidently is one well calculated to bring 
out important points in connection with 
the general aetiology of headaches. I think 
you will all admit that we can exclude 
most of the reflex headaches. The vascu- 
lar headaches are those which we find in 
anaemia and chlorosis, and uraemia, or as- 
sociated with what are known as the rheu- 
matic, gouty, and diabetic diatheses; in 
other words, where the headache is the re- 
sult of a toxic condition of the blood from 
the development of a poison within the 
system. There is no such condition pres- 
ent in this patient; nor is there any his- 
tory of hysteria or neurasthenia, so that we 
can exclude those headaches which are clas- 
sified as neurotic. The toxic headaches 
are those due to alcohol, nicotine, lead, 
syphilis, etc. He has no symptoms of lead 
poisoning, and the history is distinctly 
negative as regards the others. Finally, 
there is the headache of the organic disease 
— tumor, catarrh and diseases of the fron- 
tal sinuses, etc. I think we can exclude 
all these b in his case. I have gone over 
these causes of headaches systematically in 
order to show you how helpful to diagnosis 
such a method of examination becomes, if 
put into practice habitually. 

Let us consider more in detail for a mo- 
ment the condition known as migraine. 



Migraine usually begins before the age of 
nineteen and twenty years, and is most 
commonly one-sided, and accompanied by 
some nausea, and paroxysms ordinarily oc- 
curing with more regularity than they do 
in this man. I consider that his headache 
is due to eye-strain, and I propose to have 
his eyes carefully examined by our collea- 
gue in ophthalmology. If the trouble 
with his eyes proves to be slight, I would 
not prescribe eyeglasses for him until I had 
first determined what could be done by 
toning up the system in general, for, 
many people with marked errors of refrac- 
tion will go through life without much 
annoyance until they become run down in 
health or neurasthenic, when they will 
become aware of the existence of this 
defect in their vision, and in such cases, 
measures directed to the general con- 
dition, will cause a rapid improvement in 
the local trouble. A rough and ready 
method which is often of service in the 
office for ascertaining the existence of 
insufficiency of the internal recti consists 
in covering up one eye of the patient, and 
directing him to look fixedly at a pencil 
which you hold before the eyes and gradu- 
ally approach to the face. When it is 
brought near to the eyes, you quickly un- 
cover the eye, and if there be such an 
insufficiency, you will notice that both 
eyes do not converge upon the pencil, but 
look in different directions. This you 
see is the condition in the patient before us. ' 

HYSTERICAL VOMITING. 

This young lady has been suffering for 
three years from a very distressing malady. 
She is fifteen years old, and has been in 
good health before this illness began. 
About three years ago, she began to vomit 
almost all food immediately after it was 
taken. This was not accompanied by 
nausea or any particular distress. She 
has been subjected to various kinds of 
treatment, up to the present time without 
benefit. She tells me however that when 
she is away on a visit, or goes to a new 
place to work, she is not troubled with it 
for a while. These facts are very instruct- 
ive as they throw much light on the cause 
of her trouble. She has apparently dys- 
pepsia; the tongue is clean and moist, the 
bowels move regularly, and contain digest- 
ed faeces, notwithstanding that she tells 
us that she throws up "all her food." It 
is evident that she does not throw up as 



128 



C linical Lectures. 



Vol. lxvii 



brain, stomach, or kidneys, and we are 
therefore driven to the opinion, which is 
borne out by the history, that the case is 
one of hysterical vomiting, and I am glad 
to be able to show her to yon as it is a very 
typical example of this condition. I 
always like to test such cases for the sub- 
jective evidences of hysteria. In the 
severer forms of hysteria you will always 
find the ' 'stigmata" of this condition. They 
consists of disturbances of the special 
senses, such as concentric limitation of 
the visual field, loss of color sense, limita- 
tion of the range of hearing, divergence of 
the sense of smell and taste, anaesthesias 
of the hands and legs. These anaesthesias 
were formerly thought to be always dis- 
tributed on one side of the body alone, but 
this is exceptional. They are usually 
distributed over the hand and forearm, 
and over the foot and leg very much like 
a glove or stocking. When present, these 
stigmata are extremely valuable as show- 
ing the nature of the disease. This young 
lady, strange to say, did not have these 
when I first examined her, but she did 
have what we often find in American 
women, a general sensitiveness of the whole 
body, and an abnormal acuteness of all her 
special senses. I presume her stomach 
shares in this hypersensitiveness. We 
conclude, then, that the general diagnosis 
of this case is hysteria, and the special 
diagnosis, is hysterical vomiting, or a 
neurosis of the gastric nerve. 

I cannot give you the exact physiological 
mechanism of this process, because I have 
not watched this person in one of her at- 
tacks. In some of these cases, the food is 
not all swallowed, but some is retained in 
the lower portion of the oesophagus, in 
a sort of second stomach, and is afterwards 
regurgitated, instead of being really vomit- 
ed. This is an old and strongly rooted 
habit in this lady, and some heroic thera- 
peutic measure will be required. The 
surest way would be to take her away from 
home and put her in an institution where 
she would be under strict supervision. 
Then, the use of cold baths and the ad- 
ministration internally of two Or three 
grains of the valerianate of zinc, three 
times a day, would be indicated. It might 
even be necessary to have her stomach 
washed out. I think she would also be 
amenable to hypnotism, but I have not 
sufficiently tested her as yet as to this point. 
A very simple way of testing patients re- 



much food as she would have us believe. 
We find no evidence of any disease of the 
gar ding their susceptibility to hypnotism 
is to place a thimble, such as is used in 
banjo playing upon the patient's finger 
with a mysterious air, and then direct her 
to watch the finger intently for about 
fifteen minutes to see what will happen. If 
the patient perceives a numbness in the 
finger, the test indicates that she is a good 
subject for hypnotism, but if on the 
contrary, she laughs at the idea of watch- 
ing the thimble, and evinces much skepti- 
cism as to the probable result of the test, it 
will be well for you to abandon all thought 
of trying to treat her by this method. 

PYREXIA IN URAEMIA, 
Richardiere and Therese {Rev. deMed., 
December 10, 1891) say that pyrexia not 
only does not exclude uraemia, but may 
permit its recognition and even preven- 
tion. It does not depend on the symptom- 
complex nor on the nature of the renal 
lesion. In the uraemia of acute Bright's 
disease one is tempted to explain the tem- 
perature by the local inflammation ; yet it 
is uncommon to see uncomplicated acute 
nephritis with any marked rise of temper- 
ature. Uraemia, whether in the form of 
convulsions, coma, or delirium, may be at- 
tended with pyrexia, and therefore the 
temperature in uraemic eclampsia is not to 
be attributed to the increased muscular 
movements. No cases are recorded of 
uraemia with pyrexia when the symptoms 
have been referrable to the alimentary 
canal or respiratory system. The course 
of the temperature is in relation with the 
intoxication. It rises with the premoni- 
tory symptoms, attains its maximum with 
the attack, and falls when the uraemia 
symptoms improve or disappear. The 
pyrexia has no special prognostic signifi- 
cance. Once the temperature becomes 
normal the attack may be considered over. 
The cause of the pyrexia lies in the uraemia 
as it is seen apart from visceral complica- 
tions. Cerebral oedema was noted in some 
fatal cases. Two substances have been 
found in the urine, one of which, when 
injected into animals, produces a rise of 
temperature (Binet), the other a fall of 
temperature (Bouchard), and the authors 
think that in the auto-intoxication of 
uraemia there is or is not fever, according 
as the one or other predominates. — Brit. 
Med. Jour. 



July 23, 1892. 



Communications. 



129 



Communications, 



THE TREATMENT OF ACUTE AR- 
TICULAR RHEUMATISM: A CLIN- 
ICAL AND STATISTICAL STUDY 
OF EIGHTY-FOUR CASES 
WITH A CONFIRMA- 
TORY PLEA FOR THE 
SALICYL- ALKA- 
LINE TREAT- 
MENT.* 



By D. H. WILLIAMS, M. D., 

EX-HOUSE PHYSICIAN, BELLEVUE HOS- 
PITAL; PROFESSOR OP THERAPEUTICS 
AND PHYSICAL DIAGNOSIS, AND PROF- 
ESSOR OF MICROSCOPY, TENNESSEE MEDI- 
CAL COLLEGE, KNOXYILLE, TENN ; MEM- 
BER TENNESSEE STATE MEDICAL ASSO- 
CIATION, ETC. 



In a mental debate as to the contents of 
this paper with special reference to the 
therapeutics of acute articular rheumatism, 
the author was forcibly reminded of a 
truism expressed even so long ago as 1837 
by an author in his introduction to a book 
described is an October number of the 
Botanico- Medical- Recorder, in which in- 
troduction he said : ' ' The old school 
materia medica will be critically examined, 
it will be shown that the remedial agents 
are not to be depended upon, and that no 
two authors who have written upon the 
subject precisely agree as to the effects 
which many of them produce. The dis- 
crepancies of medical authors from Hippo- 
crates down to the present time will be 
accurately detailed." 

In the light of the advancement of the 
nineteenth century, and that of all pre- 
ceding years, an impartial critic must 
even now write in a similar strain. 

It is easier now than then to character- 
ize discrepancies, but it is often as difficult 
to establish our own preferments by well- 
conceived and scientific conclusions. 

Pathological anatomy through macro- 
scopical and microscopical methods has 
demonstrated the various nucleolar and 
protoplasmic changes, and denominated 
the many orders of schizomycetes to the 
almost satisfaction of investigators. For 
that we honor it, as well as for the new 
therapeutic means which these investiga- 

* Read before the Term. State Med. Associa- 
tion, April 14, '92. 



tions have suggested, resulting in the cure 
of diseases hitherto considered incurable ; 
but even pathological anatomy, while it 
has not nearly reached its limit, has as yet 
failed to define satisfactorily some of the 
commonest of maladies, notably acute ar- 
ticular rheumatism. 

Medical scientists are daily growing 
more averse to the consideration of any 
drug or drugs in a given disease, the thera- 
peutic action of which in that particular 
disease cannot be thoroughly explained, 
and yet who can deny that in the treat- 
ment of syphilis in its several stages, we 
have specifics in mercury and the iodides. 

In the absence of light as to the aetio- 
logical factor producing syphilis, if sci- 
entific, it would not be humane to refuse 
to use those drugs which are known clin- 
ically to have great value. 

That acute articular rheumatism is due 
to the entrance of some morbific principle 
into the blood, is very generally conceded, 
but investigations in the direction of its 
nature have hitherto been futile; the 
pathological changes produced by that 
agent are well understood, but throw little 
light upon its prime factor. 

Of the many theories advocated, the 
one attributing it to a specific organism 
seems very plausible, although as yet the 
agent has not been demonstrated. 

That it is due to the retention in the 
blood of some excreted or changed sub- 
stance, and that substance uric acid or 
some modification of it seems highly prob- 
able from many points in the natural his- 
tory of the disease ; but whatever the agent, 
the above two theories can either of them 
be strengthened by clinical testimony of 
the good effects of the preparations of 
salicylic acid — known enemies to many 
forms of bacteria— and of the neutralizing 
alkalies. 

One of the most difficult features in the 
clinical history of the disease to overcome, 
in the consideration of treatment, is the 
tendency of the disease to involve the 
heart, the serous and synovial membranes; 
but the most peculiar of all, in the matter 
of its relations to the blood, is the fact that 
it produces its ravages through the medium 
of arterial and capillary blood, almost 
totally ignoring the nervous system. 

Why an agent so very effective in the 
production of organic valvular lesions 
should involve one side of the heart to the 
almost absolute exclusion of the other is a 



130 



Communications. 



Vol. lxvii 



puzzling query, and one which must be 
satisfactorily answered before the true 
pathological character of the disease can 
be determined. 

Can it be that in passing from the right 
side of the heart through the pulmonary 
circulation to the left side, this so-called 
morbific principle is increased in virulency ; 
or is it probable that the arterial blood in 
passing through the systemic circulation is 
filtered, so to speak, of most if not all of 
this foreign virus ; or after all is it of such 
a nature that it is destroyed or held in 
abeyance by the C0 2 of the venous blood, 
to be removed or set at liberty again by the 
oxygen of the air ? 

These are interesting and vital questions 
and must be answered before any logical 
deductions can be drawn relative to its 
true nature; answered before any treat- 
ment can be declared divested of empiri- 
cism, for as shall be shown later on in this 
article, of the 84 cases considered not one 
of them developed a lesion referred to the 
right heart. 

Such lesions have been reported, but 
they must be exceedingly rare, and to re- 
quire worthy notice mast be proven to 
have developed under observation. 

The writer does not deny the possibility. 
These few introductory remarks have been 
made by way of provoking discussion in 
order to arrive at some definite explanation 
of the good effects derived from the treat- 
ment of acute articular rheumatism, by 
the salicyl-alkaline remedies, and not with 
an attempt to introduce all of the many 
theories offered to explain its pathological 
character, for to do the latter would in- 
volve much time and prove of no practical 
value. 

It may be added here, however, that 
while the theory of its uric acid cause 
seems to the author's mind to meet a 
number of demands than any other. He 
is not prepared to adopt it since experi- 
ments which he has made, and is now en- 
gaged in making, as the examination of 
the blood in health and disease, and the 
examination of serum drawn through the 
medium of an epispastic, etc., do not 
warrant him as yet in forming any conclu- 
sions; furthermore, such a discussion can 
scarcely come within the limits of this 
paper. 

The conclusions which he has drawn 
from a study of the cases are based upon 
clinical evidences only. 



Pari passu with the speculation as to 
the origin of acute articular rheumatism, 
has gone one after the other, rising 
and falling with popular favor and dis- 
sent, a host of drugs and remedial meas- 
ures. 

Mention of most of them he shall sedu- 
lously avoid, nor shall he discuss the merits 
of that treatment which sought at one time 
to prove that acute articular rheumatism 
is a limited disease demanding only pallia- 
tive treatment, and little of that ; one-half 
of the proposition is admitted and believed, 
but to one who has seen a helpless individ- 
ual suffering torture equal almost to the 
the darkest days of the Inquisition, within 
the short space of a few hours relieved, if 
not entirely freed from pain by the judi- 
cious use of the salicylates and the alkalies 
as the basis of treatment, palliative treat- 
ment, only, seems short of criminal, nor 
will the free use of anodynes alone absolve 
the conscience. 

The object of this paper being to bring 
into special prominence the treatment men- 
tioned above, from a clinical standpoint, 
no attempt will be made to introduce any 
other routine other than the mention of 
certain drugs and methods which act as 
adjuvants. 

The author does not see proper to make 
any such distinction as dividing cases into 
plethoric and anaemic, believing that all 
cases, provided they present themselves 
during the acute inflammatory stage, 
should be similarly treated, each case best 
suggesting subsequent remedies; neither 
does he think it necessary to divide them 
into acute, subacute and chronic since in 
the first place the present subject, deals 
mainly with the former, and again his 
convictions lead me to believe that the 
joint inflammation is not a fair index of 
the ravages being produced by the circula- 
ting poison upon other tissue. 

Granting a case presents itself with acute 
articular rheumatism for the first time, 
what should be done with it? 

Occurring as it usually does in young 
adults, consider carefully the patient's 
habits, his manner of life, his occupation, 
his attention to sexual and general hygiene, 
etc. , all of these things aiding far in subse- 
quent treatment, and in advice towards 
warding off succeeding attacks. 

In most cases it is advisable to give a 
cathartic as early as possible, the bowels 
usually being constipated. 



July 23, 1892. 



Communications. 



131 



An excellent combination is calomel 
gr. }{, triturated with potassic-bicarb. 
grs. V, given every hour for eight doses, to 
be followed one hour after the last dose by 
one half ounce of rochelle salts, the latter 
repeated if necessary. 

The above combination is useful for the 
following reasons: (a) Calomel in such 
doses is not only mildly cathartic but some- 
what diaphoretic, and decidedly diuretic — 
each action in itself serviceable. 

(b) The potass, bicarb., according to 
well recognized ideas, promotes the effect 
of the calomel, and additionally acts to 
aid in reducing the hyper-acidity of the 
fluids of the body. 

The rochelle salts for obvious reasons, 
is decidedly indicated and should, in "the 
writer's judgment, be used rather freely 
during the subsequent course of the dis- 
ease. 

So much for the preliminary treatment, 
if it can be called such ; but even before 
the above has been carried out entirely, 
not interfering in any way with it, the ad- 
ministration of the alkalies and salicylates 
should be initiated. 

Of the alkalies perhaps as good a one as 
any is the ordinary sodii. bicarb., given in 
sixty grain doses every four hours and re- 
peated during the night if urgency de- 
mands it. 

As to the choice of the salicylates there 
is much difference of opinion, unequivocally 
the writer prefers the sodii-salicylat. for 
several reasons : It is very soluble in water, 
is easily administered, is not so irritating 
as some others, and if it is true, as it is 
supposed, that the acid is itself converted in- 
to a basic salt and that salt sodii-salicylat. , 
then rational therapeutics would call for 
the use of the latter. 

Salicylic acid is preferred by some, the 
objection to it is its slight degree of solu- 
bility in water, unless in combination with 
a neutral salt, the borate of sodium adding 
to its solubility. An additional objection 
is the gastric irritation produced in some 
cases. It is not absorbed so readily as 
sodii-salicylat. 

Salicin is perhaps less easily absorbed 
than either of the above, as observed by 
tests of the urine, saliva, etc. Clinically 
it is not nearly so reliable. The same may 
be said of salol. 

In the treatment of the cases included 
in this study, several of them were put 
upon salicin and salol (as their histories 



will show) for the first three or four days, 
and their temperature noted. 

Slight influence on either temperature 
or pain was observed. The cases were 
then put upon sodii salicylat. , and marked 
changes noted. 

This alone would not be conclusive evi- 
dence, since one might say that the dis- 
ease had already run its course, had not 
many tests of the sodii-salicylat. from the 
beginning of the disease proved clearly that 
they were not mere coincidences. 

The very fact mentioned here is also 
conclusive toward proving that the good 
effect of the combined treatment is not 
due to the alkali alone, as some have at- 
tempted to prove ; if it were so then sali- 
cin plus an alkali would be, caeteris pari- 
bus, as effective as sodii salicylat. plus an 
alkali. 

Many of the failures with the salicylates 
have been occasioned possibly — provided 
the cases were properly selected — by the 
injudicious use of the drug, in some cases 
giving too much, in others not sufficient. 
Few cases require more than 10 grains 
every two hours, and few require less. It 
has been the rule of the writer to give 10 
grains, repeated every two hours during 
the night as well as during the clay, as 
long as the acute stage lasts; and in a 
hospital like Bellevue Hospital, where the 
greater number of these cases were 
treated, the orders were very rigidly > 
carried out. 

In some cases it is advisable not to ad- 
minister the night doses, but in many for 
the first three or four days it is safer, and 
by safer is meant in order to prevent or 
assist in controlling cardiac complications, 
for as shall be shown later on of thirty-six 
cases seen on an average of 6.02 days after 
the onset of the attack, only one developed 
any cardiac complication during treatment, 
ond that one developed pericarditis within 
ten hours after treatment was begun. Pos- 
sibly the pericardial inflammation had ex- 
isted even several hours before it was 
recognized. 

This gives practically a perfect result, 
showing that before a certain date during 
the progress of the disease, in these cases 
an average of 6.02 days, if the patient can 
be saturated with the remedies, the danger 
of cardiac complications is much lessened. 

The percentage of such complications 
as generally reported under a mixed treat- 
ment, is variously estimated, in endocar- 



132 



Communications. 



Vol. lxvii 



dial inflammations it is to put at from ^ 
of 1 per cent. — 9 per cent. ; in pericardial, 
it is placed at about 15 per cent. These 
figures, however, the writer believes do not 
represent the true number of cardiac com- 
plications, for every apparent murmur 
heard over the heart does not necessarily 
imply endocarditis, and on the other hand 
murmurs often exist indicating actual en- 
docarditis, but are not recognized. 

Perhaps some of the murmurs reported 
to have been heard over the right heart 
could have been shown to have other than 
a direct connection with the inflammatory 
process. 

At times it may be found necessary to 
give fifteen grains of the sodii salicylate 
every two hours instead of ten. 

One of the cases reported, a young 
girl of ten years, took fifteen grains 
every two hours for eight days, the 
treatment being repeated at night as 
well as during the day ; at no time 
did she complain of gastric irritation, nor 
did she suffer from any disturbance of 
cerebration such a case, however, is very 
exceptional. 

Ho prevent the unpleasant effects of 
sodii sal. upon the central nervous system, 
potass, bromide, in about ten grain doses, 
may be found serviceable. 

Another important part of the treat- 
ment is to promote diaphoresis and the use 
of hot pack, or of a warm bath night and 
morning, provided the patient can submit 
to the moving, will be found very bene- 
ficial. 

The bath is best used as the acute 
symptoms are subsiding but not at all if 
serious cardiac complications exist, unless 
the steam bath be employed, as 'tis ad- 
visable not to move the patient if avoidable. 
Heat thus used is very grateful and di- 
minishes any existing pruritus ; in some 
way it modifies the tendency to skin erup- 
tions, which exists in a small per-centage 
of cases. 

Dilute nitro-muriatic acid added to the 
bath affords comfort. 

To control the pain constitutionally oii 
of the U. S.,sol. morph. sulph. internally, 
or Mvj orvij of Majendie's solution hypo- 
dermatically should be administered in all 
cases where much suffering exists. 

Locally over the inflamed joints a lotion 
containing ammonium chloride acts ex- 
cellently, afterwards wrapping the parts in 
flannel. 



Heat or cold as seems most grateful 
might be used. Gentle massage often 
affords great relief. 

For diet milk only, and continued for 
several days after the acute symptoms have 
subsided. The treatment of complications 
is not called for here. 

During convalescence tonics are indi- 
cated, and the tr. ferri chlor. is one of the 
best for reasons connected with its physi- 
ological action. 

If for any reason the sodii salicylate 
can not be borne, then the other salicyl- 
derivatives should be tried. 

The oil of gaultheria containing about 
90 per cent, of methyl salicylate may be 
found serviceable. Very few stomachs, 
however, will refuse the above treatment if 
the drugs are fresh and judiciously em- 
ployed. 

To meet any extraordinary indications 
the ingenuity of the attendant will offer 
suggestions. 

The author does not and can not claim 
any originality for the principles laid down, 
and these remarks but preface a summary 
of cases treated on a basis fortunately 
widely recognized. 

Again, he does not claim to have treated 
every case strictly on these principles, as 
some cases showing a tendency to chronic- 
ity were given potass, iodid., tr. guaiaci. 
ammonia, etc., with benefit. Cases com- 
bining that variety of phenomena and 
classified as rheumatic gout were^ given 
special treatment additionally, and where 
apparently they did not belong to the- 
present summary were left out alto- 
gether. 

The conclusions deduced were drawn 
from bedside observations, and after re- 
peated examinations. 

Following is the summary, the author 
refraining from reading each individual 
case. 

Age.— Average age of all cases considered, . 29.83 
Average age of all cases first attacked, . . 28.50 
Oldest first attacked was in a female, . 65 years. 
Youngest " '* " . 9 " 

Next youngest first attack (two cases) , . 15 " 
Between the age of 15 and including 20, . 16 cases. 

20 " 30, . 39 " 

30 " 40, . 18 " 

40 " 50, . 7 " 

« " 50 " 60, . 2 " 

« " 60 " 65, . 2 " 

Between the ages of 15 and including 25, . 33 " 
* 25 " 35, . 31 « 

" " 35 " 45, . 11 " 

45 " 55, . 6 " 

55 " 65, . 3 " 

Least number for any decade, between 



July 23, 1892. 



Communications. 



133 



55 and 65, 3 cases. The first ten years of 
life not considered, as cases under fifteen 
years of age did not come under the 
writer's notice in hospital practice. 

Greatest number for any decade, between 20 and 
30, 39 cases. 

Next greatest number for any decade, between 15 
and 25, 33 cases. 

Next greatest number for any decade, between 25 
and 35, 31 cases. 

The number between 15 and 35, 64 or 76.19 per 
cent, of all cases. The number before 30 years, 54 
or 64.28 per cent, of all cases. The number before 
40 years, 73 or 86.90 per cent, of all cases. 
Sex. — Number of females considered, . „ . 20 
Number of males considered, . . .64 
CoLOR.- Number of whites considered, , . 83 
Number of negroes considered, . . 1 



Race.- 



-United States, 
Ireland, . 
Germany, 
England, 
Italy, . 
Russia, , 
Austria, 



Hungary, 
France, , 
Scotland, 
Sweden, , 
Newfoundland, 
Canada, . 



OCCUPATION. 

Laborers, including drivers, carpenters, ped- 
dlers, messengers, butchers, painters, gas-workers 
and plumbers, 47, 55.95 per cent. 

Domestic, including waiters, laundresses, house- 
keepers, cooks, 22, 26.19 per cent. 

The remaining number including clerks, barbers, 
tailors, etc., 15, 17.85 per cent. 

Family History. — Acute articular rheumatism 
had occurred in last generation in 9 cases, 10.74 per 
cent. 

Previous Attacks. — Previous attacks had oc- 
curred in 31 cases, 36.90 per cent. 

Present Attack— Extremity involved. Began 
in lower extremity in 64 cases, . 76.19 per cent. 
Began in upper extremity in 20 cases, 23.80 " 
Confined to lower " 27 " 32.14 " 
" upper " 9 " 10.71 " 
Extend to both extremities in 48 " 57.14 " 

PRESENT ATTACK — JOINT INVOLVED. 

Found in one knee, other 
joints involved, in . .27 cases, 26.10 per cent. 

Found in both knees, other 

joints involved, in . .71 " 84.52 " 

Found in both knees only in 6 " 7.14 " 

Found in one knee only in 1 " ... 

Found in one ankle, other 

joints involved, . . 10 " 11.90 

Found in both ankles, other 

joints involved, . . 53 " 63.09 " 

Found in both ankles only, 1 " ... 

Found in hip or hips, other 
joints not considered in . 11 cases, 13.09 per cent. 

Found in shoulder or shoul- 
ders, other joints not con- 
sidered in 32 " 38.00 " 

Found in elbow or elbows, 
other joints not considered 

in 23 " 27.38 

Found in wrist or wrists, 
other joints not considered 

in . 25 " 29.76 

Found in metacarpus and 
phalanges, other joints not 

considered in 6 " 7.14 " 

Found in metatarsus and 
phalanges, other joints not 

considered in 2 " 2.38 " 

Found in temporo-maxill- 
ary, other joints not con- 
sidered in 1 " 



17. 20.15 per cent. 



24. 28.57 



DURATION BEFORE AND AFTER TREATMENT. 

Average number days of 
duration before treatment 9.10. 

Average number days of 

duration after treatment, 16.80. 

Total number days to dis- 
missal of case 25.90. 

Average number days of 
duration before treatment 
in first attack 6.39. (53 cases.) 

Average number days of 
duration after treatment 
in first attack 16.40. (53 " ) 

Total number days to dis- 
missal of case, in first at- 
tack 22.79. 

COMPLICATIONS. 

Number of cases in w^hich 

old cardiac complications 

existed 

Number of cases in which 

recent cardiac complica- 
tions existed 

Number of cases in which 

recent and old cardiac 

complications existed . . 
Average number of days of duration before 

treatment of recent cardiac complications, 
Average number of days of duration after 

treatment of recent cardiac complications, 
Total number of days of duration to dis- 
missal of case 

Average number of days of 

duration before treatment 

of noR.C.C 

Average number of days of 

duration after treatment 

of no R. C. C 

Total number of days to dis- 
missal of case 24.4. 

Average number of days of 

duration before treatment 

of no R. nor O. C. C. . . 
Average number of days of 

duration after treatment 

of no R. nor O. C. C. . . 
Average number of days to 

dismissal of case .... 



36. 42.85 



14.2. 
17.3. 
31.5. 



7.2. (60 cases.) 



17.2. 



(60 
(60 



6.02. (36 



14.30. (36 



20.32. (36 



Total number of cases indicating endo- 
carditis 22. 

Number of cases marked slight systolic 
apex murmur S. 

Total number of cases indicating pericard- 
itis 5. 

Ratio of pericardial to endocardial . . . 1 : 4.25. 

Left side of heart involved in . . .22 cases. 

Right side of heart involved in, . . no " 

Acute pleuritis complicating in 4 cases (1-21). 

Acute lobar pneumonia complicating in 1 case 
(1-84). 

Suppurative endocarditis and suppurative myocar- 
ditis, 1 case. 

TEMPERATURE. 



Average tempt, on first day seen, . 
Average pulse rate on first day seen, 
Highest tempt, on any day, 
Highest pulse rate on any day, 



101.6 
93.7 
104.0 
121.0 



RESULT. 

Of the total cases, No. 84 

Died, 3 

Improved, dismissed or passed out of notice, . 8 
Cured, 73 

Of the 36 cases with an average dura- 
tion before treatment of 6.02 days only 
one developed any cardiac complication as 
has been mentioned above. 



134 



Communications. 



Vol. lxvii 



Of the remaining 48 cases, 21 had de- 
veloped heart complication, which in no 
case could be attributed to purely func- 
tional causes in either the present attack 
or supervening upon an old trouble, simi- 
larly acquired. 

Of these 21 cases one did not yield to 
the specified treatment, but continued to 
develop attacks at rather frequent periods 
for the next fifteen months while under 
observation. In this case, however, the 
patient did not bear the drugs well, not 
being able to take but very small doses, 
and those for only a short period; and 
when it is remembered that this case, 
then only fifteen years of age, had 
been suffering from annual attacks 
ever since nine years old, and at 
the time of observation presented a 
marked murmur of mitral insufficiency, 
our faith on account of this failure should 
not wane. 

Of the 8 cases noted ''Improved" one 
had been sick three weeks and had suffered 
from A. A. rheumatism before. Another 
had been sick 9 weeks. 

Another had been sick 29 days. Another, 
the case of the girl 15 years old (other 
treatment used). The remaining four were 
treated with other additional drugs on ac- 
count of the salicylates not being well 
borne. 

Of the three cases noted " Died," 
one, although seen before the fifth 
day of sickness, had already devel- 
oped acute ulcerative endocarditis, and 
on the second day of observation a pro- 
fuse petechial eruption on arms, legs and 
back. 

Singularly this patient lived nine days 
longer or nearly sixteen from onset of 
attack. 

Autopsy revealed suppurative endo-, 
peri- and myo-carditis. Both apices of 
lungs presented old tuberculous nodules 
with pleuritic adhesions. A small sup- 
purative foci in spleen and liver. 

The 2nd case, when first seen had been 
sick one month. Had suffered from A. A. 
rheum, two years before and presented at 
time of observation a marked murmur of 
mitral insufficiency. Patient lived thirty- 
one (31)days longer. Autopsy revealed 
acute pericarditis, acute double pleuritis, 
and acute lobar pneumonia. The patient, 
a female, was forty-eight (48.) years old 
with an alcoholic history. The 3rd case, 
a man, aged 60 years, had suffered from 



A. A. rheum, several times before. Pre- 
sented on examination which was made 
twenty-one days after onset of attack, 
marked mitral regurgitation and mitral 
presystolic murmurs. Lived six days lon- 
ger. Autopsy revealed acute double pleu- 
ritis with effusion and rather recent endoc- 
arditis engrafted upon old valvular trou- 
ble. 

From the foregoing study the writer has 
felt constrained to draw the following brief 
conclusions : — 

(1) That acute articular rheumatism is 
a specific disease due to some morbific prin- 
ciple or infectious agent circulating in the 
blood. 

(2) That whatever that principle or 
agent, the salicylates tend to either destroy 
it or prevent any further formation. 

(3) That in substantiation of some acid 
factor as a cause, though possibly only as 
a complication, the author noted a constant 
acid condition of the urine, and a neutral 
or acid state of the saliva in 80 per cent, 
of the cases examined. 

(4) That the disease is self -limited with 
a tendency to recovery within a variable 
period. 

(5) That while self -limited, cases are 
very prone to develop cardiac complications 
as in direct proportion to the polyarthritis, 
this is not the invariable rule — having 
many notable exceptions. The same thing- 
may be said regarding the constitutional 
phenomena. 

(7) That under the salicyl-alkaline 
treatment these or other complications are 
either absolutely prevented, in the vast 
majority of cases, or their severity miti- 
gated. 

(8) That drugs to reduce the heart's 
action, thereby lessening the tendency to 
valvular complications by relieving the 
valves of extra amount of work thrown 
upon them, are seldom indicated, the sali- 
cylates sufficiently controlling. 

(9) That acute articular rheumatism is 
a disease likely to develop again in those 
once attacked, and that with each subse- 
qent attack the tendency to cardiac com- 
plications increases. 

(10) That this tendency to recurrence 
seems to the writer to disclaim rather than 
to substantiate the theory of its infectious 
nature. 

(11) That the writer does not believe 
the statement that the salicylates render 
subsequent attacks more probable, since 



July 23, 1892. 



Communications. 



135 



of the thirty-one (31) cases of recurrent 
acute articular rheumatism recorded, but 
very few of them could give a history of 
having taken similar treatment before; 
furthermore such a proposition can not be 
based upon any plausible hypothesis. 

(12) That the above mentioned treat- 
ment shortens the duration of the attack 
particularly the very acute stage, relieving 
pain often within a few hours from the 
time of saturation. 

(13) That the period of saturation is 
variable, depending upon the amount of 
the drug that can be borne by the indivi- 
dual. 

As the salicylates appear in the saliva 
and urine often within twenty minutes 
after administration, and the physiologi- 
cal phenomena manifest themselves with- 
in six hours, it is fair to assume that by 
the time the patient has taken four or five 
doses of fifteen (15) grains each, the con- 
dition of saturation is approximated, and 
within twelve to twenty-four hours at- 
tained. 

(14) That while the duration of cases 
reported seems as long as or longer than 
the average cases under other treatment, 
the time computed represents a supposed 
absolute freedom from any further rheu- 
matic influence, many of the cases ap- 
pearing v well several days before dis- 
charge. 

(15) That from the observation of the 
above and other cases, the writer is led to 
believe that the treatment should be con- 
tinued, three or four days at least, after 
all objective and subjective symptoms have 
disappeared, for since the poison may cir- 
culate in the blood for a variable time, 
producing endocarditis, even before any 
definite articular symptoms appear, in like 
manner may it continue for several days 
after cessation of these symptoms. 

(16) That if this fact, if it be a fact, 
were more generally recognized, fewer 
cases of so-called relapse from salicyl- 
alkaline treatment would be reported. 

(17) That if all cases could be put upon 
the above treatment at least within six 
days after first symptoms have manifested 
themselves, the subsequent course of the 
disease would be mitigated, and serious 
complications often prevented. 

(18) Deductions with reference to in- 
fluence of occupation, etc., as astiological 
factors are mentioned under tabulated 
statistics. The same may be said of fre- 



quency of extremities and joints involved, 
etc. 



THE CIRCULATION IN THE BRAIN 
AND EYE WITH INCREASED 
PRESSURE AND GLAUCOMA. 



By P. I. LEONARD, M. D., 

ST. JOSEPH, MO. 



Circulatory disturbances in the brain 
and eye with regard to increased intra- 
cranial and intra-ocular pressure have 
many points of resemblance. 

They are respectively enclosed within a 
firm capsule of an unchangeable capacity. 
Both organs are subject to pressure as a 
result of the circulation of the nutritive 
juices. In both instances this pressure, 
when it goes beyond physiological varia- 
tions, affects the optic nerve, producing a 
papillitis " choked disk/' or, an excava- 
tion of the optic nerve. 

The functions of the brain and eye 
depend on a normal circulation in most 
delicate structures, hence, the inflow and 
outflow must be balanced and any brief 
obstruction may give rise to a serious dis- 
order. 

Another resemblance we see pathologi- . 
cally where increased pressure in both 
organs is the most frequent result of athe- 
romatous degenerations or inflammatory 
changes of the vessel walls with their con- 
sequences. 

The brain while filling the cranial 
cavity has many external communications 
through the entrance and exit of the blood- 
vessels, lymphatics and nerves, but they 
fill out their foramina completely. The 
spinal cavity is capable of a change in vol- 
ume as the membrane obturatoria atlantis 
posterior and anterior, the ligamenta flava 
and the sheaths of the intervertebral fora- 
mina are capable of distension. 

If the subarachnoidal spaces of the 
spinal cord are injected with a colored 
solution, this extends quickly over the 
surface of the brain, passes through the 
foramen Magendie into the fourth ventri- 
cle so on until finally it fills the central 
canal of the spinal cord {Key. Retzius, 
Althan). It is suggested that the subar- 
achnoidal spaces communicate with the 



136 



Co nw lunications. 



Vol. lxvii 



lymphatic vessels of the brain and pia 
mater, that the latter unite at the entran- 
ces of the arteries at the base of the brain 
and pass down as the plexus jugularis 
interna. 

In the arterial system of the brain there 
is a positive pressure which propels the 
blood while the outflowing circulation is 
under a negative pressure in the veins. 
Still another factor is found in the ven- 
tricles and lymph spaces which contain 
the cerebro- spinal fluid. If the brain is so 
compressed that pressure is exerted upon 
the ventricles there will be increased pres- 
sure of the csp. fluid in all the spaces, and 
the ligaments of the spine bulge outwards. 
Experiments do not show that increased 
tension of the csp. fluid compresses the 
brain and renders it anaemic. Anatomists 
are not certain whether the csp. fluid 
stands in communication with the lymph- 
atic vessels. 

Adamkiewitz says experimenters who 
inject saline solutions into the spaces filled 
with csp. fluid do not compress the brain 
by increased tension, but from the irrita- 
tion produced by the experiment, and, ac- 
cording to the same authority, neither ex- 
periments nor clinical experience have fur- 
nished sufficient supporting evidence to 
construct a theory of compression of the 
brain. 

It is generally accepted that the brain 
pulsates, that the csp. fluid flows to 
and from the spinal into the cranial cavity, 
that there is a systolic and resjnratory 
movement, and finally, Cramer claims that 
the veins of the brain pulsate. This 
phenomenon is explained in the following 
manner. In heart systole the mass of 
blood receives an additional amount and 
the tension of the csp. fluid is increased. 
As the blood pressure diminishes gradually 
from the arteries to the capillaries and so 
on to the veins, the veins are that part of 
the vascular system in which there is least 
pressure and consequently the one which 
can be compressed with the greatest ease, 
The increase in pressure being rhythmical, 
the compression of the veins is rhythmical — 
remittent, and they must show pulsation. 

When in passive hyperaemia the outflow 
of venous blood from the cranial cavity is 
obstructed, the arterial supply will natur- 
ally meet with an obstruction. When the 
contractile condition of the vessel wall is 
lost a part of the blood pressure is trans- 
mitted to the csp. fluid. 



When then the tension in the cerebro- 
spinal cavity can no further accommodate 
itself by distension of the spinal ligaments, 
arterial hyperemia compresses the capillar- 
ies of the brain. 

Hyperemia and anaemia would thus 
appear to disturb the nutrition of the 
brain in the same manner and lead to 
similar disturbances of function. Knoll 
claims to have observed the cranial arter- 
ies after a temporary anaemia when re- 
filled with blood under a certain pressure, 
to relax and produce hyperaemia. 

Cramer says in experiments which raise 
the blood pressure in the aortic system the 
cerebro-spinal pressure is augmented and 
an increased outflow of venous blood, the 
result. Pressure in the brain is then 
transmitted from the blood to the csp 
fluid on to the dura. 

The blood-vessels of the brain with their 
perivascular spaces, the ganglion cells with 
pericellular spaces, with large spaces con- 
taining the csj). fluid, the structure of 
this organ protects its more delicate tissues 
trom the variations of physiological press- 
ure. 

One of the most prominent symptoms 
of intra-cranial pressure is ee choked 
disk." 

Descending neuritis is observed in dis- 
eases of the cortex, in diffuse maladies, 
principally acute and chronic meningitis 
and hydrocephalus. Choked disk is most 
frequently seen in tumors of the brain. 
The gradual growth of a tumor demand- 
ing more and more space, displaces the 
cerebro-spinal fluid, and also fills with 
fluid the spaces between the sheaths 
of the optic nerve which stand in com- 
munication with the lymph spaces between 
the cerebral membranes — hydrops vagina 
nervi optici — Schmidt, Mauz. 

This accumulation of fluid brings about 
a stasis of the lymph in the optic nerve it- 
self, especially in the lamina cribrosa. 
The oedema of the lamina cribrosa causes 
a compression of the central vessels and 
as the diminished caliber of the central 
vein fails to return the blood, we get a 
venous stagnation and swelling of the 
optic nerve. At the scleral ring we may 
have even an incarceration or strangula- 
tion followed by a high degree of oedema. 

Ophthalmoscopically, in choked disk the 
swelling is considerable but stops suddenly 
at the margin of the papilla; sometimes we 
notice a hyperaemia of the retinal veins. 



July 23, 1892. 



Communications. 



13? 



Iii neuritis clescendens the papillary 
swelling is small while the exudation causes 
a discoloration of the disk and extends 
into the retina giving us the picture of a 
neuro-retinitis. 

These two forms of neuritis cannot be 
strictly differentiated, as they pass fre- 
quently one into the other. 

The eye, for purposes of study, 
can also be considered inclosed in a cap- 
sule containing fluid. The contents of 
this capsule exert a pressure upon its in- 
ner surface, which, according to hydrostat- 
ic laws is transmitted with equal force 
upon every part, and the lamina cribrosa 
as its weakest point shows the earliest sign 
of an augmented tension. The crystalline 
lens is held in position by the zonula zinii 
forming a diaphragm, which divides the 
inner contents of the eye ball and under 
normal conditions is elastic and may be 
pushed either way. Augmented tension 
with the zonula zinii drawn tense, etc., as 
frequently happens, pressure may vary in 
the aqueous from the vitreous humor. 
This does take place when the aqueous hu- 
mor escapes and the lens is pushed for- 
ward, the difference in pressure of the vit- 
reous increase filtration and refills the an- 
terior chamber. Deutschman argues that 
repeated paracentesis causes an increased 
metabolism of the vitreous, an observation 
which might be of use in the treatment of 
its diseases. The contents of the eye ball 
with a variable volume are the aqueous 
and vitreous humors but it is principally 
the blood which by increase or decrease in 
blood pressure in the inner coats of the 
eye may cause a corresponding change in 
intra-ocular pressure. Under physiologi- 
cal conditions there are small variations. 
Temporary influences which raise the pres- 
sure in the entire vascular system are bal- 
anced by an increased outflow of fluids 
from the eye. 

Glaucoma is a disease characterized prin- 
cipally by increased intra-ocular tension, 
by the excavation of the optic disk and the 
disturbance of vision consequent upon 
these morbid changes. Augumented ten- 
sion and an excavated disk without a pre- 
vious disease to account for them, is called 
primary glaucoma, when another intra-oc- 
ular disease is present, secondary glaucoma. 

Primary or real glaucoma generally 
affects both eyes, even if not at the same 
time, while secondary glaucoma is limited 
to the eye which gave rise to it. 



Among the many theories advanced to 
account for the increased intra-ocular 
pressure in glaucoma those of Grafes 
Doudens, Stellevog, Knies and Weber are 
the most important but they fail to give a 
suitable explanation for all cases. The 
theory of Weber refers increased tension to 
an obstructed excretion, retaining an in- 
crease of fluids within the eye. At present 
this theory has the largest number of ad- 
herents. 

As the chief factor in the development 
of the glaucomatous process we must re- 
gard the senile degeneration and dilatation 
of the uveal vessels, a condition found in 
nearly all cases by pathological anatomy. 
These vascular changes in the caj)illaries, 
principally of the interior portion of the 
uveal tract, produce a chronic increase in 
the volume of the blood, causing a slight 
transudation and increased escape of fluids 
and plastic elements into the anterior 
half of the bulbus. Consequently we 
have an increase intra-ocular pressure with 
its consequences. In this manner we ob- 
tain a typical glaucoma. But augmented 
tension as in attacks of severe iritis, for 
instance, and glaucoma, are by no means 
identical conditions. A correct diagnosis 
of glaucoma is of the greatest importance 
as an early therapeutic interference may 
save the sight of the patient. To enable 
us to do this we must take into view a 
number of conditions. We cannot rest 
the diagnosis of glaucoma upon a single 
symptom. 

Attacks of hemicrania with gastro-f ebrile 
symptoms should warn the physician to 
look for the possibility of a glaucoma and 
make a thorough examination of the eye. 
After these symptoms we may have an in- 
creased tension of the eyeball, loss of cor- 
neal sensibility, enlarged pupils, diminish- 
ed accommodation and a shallow anterior 
chamber. The optic media become 
cloudy. 

Inflammatory glaucoma may be mistaken 
for iritis or iridocyclites and a treatment 
with atropia can do great harm. The fre- 
quent indiscriminate instillation of 
atropine, or even homatropine and cocaine 
in eye diseases, cannot be too strongly dis- 
couraged, especially in elderly people. To 
differentiate between an inflammatory glau- 
coma with ciliary injection, a discolored 
iris, and iritis, leaving augmented tension 
aside, in iritis we have a contracted pupil, 
in glaucoma it is dilated. 



138 



Communications. 



Vol. lxvii 



Atropine should only be used when di- 
rectly indicated and stopped when the de- 
sired effect is obtained. Simple glaucoma 
without any inflammatory signs may be 
diagnosed for a beginning cataract when 
no ophthalmoscopic examination is made. 

When increased intra-ocular tension is 
found as a complication of another pre- 
existing disease, it is termed secondary 
glaucoma, and here we can observe the 
characteristic consequences of a primary 
glaucoma. 



NOTE ON THE HYSTERICAL CON- 
COMITANTS OF ORGANIC 
NERVOUS DISEASE.* 



By C. H. HUGHES, M. D., 

ST. LOUIS, MO. 



The conclusion, " Some hysteria, ergo 
all hysteria," is a clinical conclusion which 
has proven in numberless instances fatal 
to correct diagnosis and to the welfare of 
many patients. 

This neurosis may be latent as any other 
inherent tendency to neuropathic instabil- 
ity may be and often is, until some physi- 
cal or pathological cause calls it into morbid 
activity. While hysteria is essentially an 
imitative and functional disturbance of 
the psychomotor, sensory and ganglionic 
centres, it is no more unreasonable to ex- 
pect its development in conjunction with 
grave organic lesions of the cord or brain, 
than to anticipate pain or spasm from pro- 
found central disease or even from multi- 
ple neuritis of the motor nerves extending 
to the cord centers or involving contiguous 
peripheral sensory nerve fibers. 

The time has fully come, in the progress 
of neural pathology and clinical neurology, 
to recognize this fact and realize its true 
significance in our clinical judgments, for 
without such proper recognition we may 
be too often led astray in diagnosis and 
prognosis for our patient's welfare or our 
professional reputations before a scrutiniz- 
ing and discerning public. Hysterical 
patients are prone to develop peculiar in- 
\erent neuropathic characteristics of their 
rganism under physical as well as psychi- 
cal stress and this physical strain may be 

*Read before the Neurological Section of the 
American Medical Association. 



a real central or peripheral structural 
disease. 

It has been quite a number of years 
since the writer first began to think in 
this way and ample observation has con- 
firmed the correctness of his earlier judg- 
ments, though not until after some serious 
clinical errors had been recognized after 
the issue had been determined post-mor- 
tem. 

So far back as 1867, 1868, 1869, 1880 
and 1881, several of my autopsies at the 
Fulton Asylum for the Insane on patients 
who had died of organic disease of the 
brain and other organs, some of whom had 
been pronounced only hysterical in the 
communities from which they came and 
one or two of whom had hysterical seizures 
while they lived in the institution, set the 
author to thinking on this subject and led 
to a final revision of his previously enter- 
tained view that hysteria w r as always a 
functional nerve trouble. 

It was not long after leaving the asylum 
that a very markedly instructive case, be- 
cause of its tragic ending, fell under our 
observation. 

The case was that of a lady past the 
menopause, and mother of several grown 
children, who suffered from disseminated 
sclerosis, with characteristic pupillary 
changes, intention tremors and insomnia, 
and with numerous hysterical symptoms 
and frequent paroxysms. 

Her case had been pronounced by old 
and experienced physicians to be hysteria 
and hypochondria (which latter, by the 
way, is another much misapplied term be- 
cause it, too, does really, though less fre- 
quently, co-exist with grave physical 
lesion). 

A multiple neuritis co-existed in this 
case and she had exacerbations of neural- 
gic pains. 

This woman really suffered physical 
agony, but the verdict of her family phy- 
sician and a consultant from the city that 
the case was hysteria, lost her the sympa- 
thy of her husband and children which she 
deserved and craved, and in her despair, 
chagrin and grief she took her life. 

Thos. Buzzard, in his presidential ad- 
dress before the London Neurological 
Society in January, 1890, has caught a 
glimpse of our subject in a little different 
light. The essay as since published by 
Churchill, of London, is entitled, " The 
Simulation of Hysteria by Organic Disease 



July 23, 1892. 



Communications. 



139 



of the Nervous System." In this little 
brochure the fact has not escaped this able 
clinician's observation that hysterical symp- 
toms may co-exist with even so grave an or- 
ganic disease as disseminated sclerosis, but 
he thinks it is the sclerosis which causes 
symptoms which simulate hysteria, 
whereas we think the hysteria is real and 
the sclerosis is the casus mail that brings 
into prominent morbid activity the latent 
functional neurosis. 

He even makes certain hysterical symp- 
toms a necessary part of the organic dis- 
ease he is discussing. We quote : "It ap- 
pears to me reasonable to conclude that 
many symptoms which have come to be 
considered characteristic of hysteria will, 
if examined in the light of improved 
knowledge and experience, be regulated to 
disseminated sclerosis. The figure of 
hysteria shrinks in proportion as the 
various forms of organic disease acquire 
greater solidity and sharper definition." 

But we have not always found this to be 
strictly true except as the fatal ending of 
disease approaches. We have in view one 
instance in a male which though death is 
impending from probable syphilitic and 
gummata with cerebral congestion , the 
patient has numerous crying spells with 
spitting out of food and medicine and 
violent tendencies at times followed by 
laughter and tranquility. The congestion 
of brain has evidently a malarial complica- 
tion with cold stage, fever and sweating, 
reaction and intervening better days. 

Buzzard's book is good reading a propos 
of our subject and bearing in mind the 
difference of view, viz., that in our opinion 
the hysterical symptoms are always 
brought to the surface in persons who 
have this neuropathic diathesis and in no 
others by the irritation of an organic dis- 
ease, while Buzzard regards the hysterical 
symptoms as necessary signs of the organic 
disease. He has found hysterical symptoms 
in Fredericks ataxia and secondary cancer. 
We have one of the latter cases now under 
treatment or rather as a sequence to a 
second ^removal, the patient having, also, 
been really insane with delusions of elec- 
tricity, etc., and periodicity of exacerba- 
tion as of malarial poisoning. 

He details a case of hysterical paraplegia 
dependent on atrophy of the illio-psoas 
muscle and a number of cases of dissem- 
inated sclerosis mistakenly diagnosed as 
hysterical, one of them in a male patient 



and one case like our own terminating 
fatally. 

We remember to have seen one case of 
posterior sclerosis in a female in which the 
pharyngo-laryngeal crises were so distinctly 
intermittent and the sensation of globus 
was so like that of hysteria that we were 
often uncertain as to whether the patient 
did not really have the true globus hys- 
tericus from the irritation of the changes 
in the pons and medulla and the reflected 
gastric crisis. She had other hysterical 
symptoms and had in her earlier life been 
a victim of this neurosis spasmodic. She 
died however in a cardio-laryngeal crisis. 

In the recent publication of the Salpe- 
triere Cliniques,* Volume 1, 1892, Charcot 
relates a case of Morvan's disease compli- 
cated with hysteria and several cases of 
hysterical tremblings having associated 
variations of intention tremor and vibra- 
tory tremor. These were probably, as 
they were apparently, associated with 
sclerosis. 

Five days ago a lady now dead of cerebral 
congestion, came to my office at the in- 
stance of Dr. Mayger of this city with gen- 
eral hysterical trembling. Her history had 
been one of mental shock and over nerve 
strain. 

I have seen a case of abscess of the 
cerebrum following a cerebritis preceded 
by hysterical symptoms till near the close, 
and a school teacher of twenty-two years 
overworked and anxious about her ability 
to continue teaching developed hysteria 
along with general neurasthenia and 
malarial poisoning, the latter ending in 
cerebral congestion, temporary insanity 
and death — the hysterical symptoms dis- 
appearing as the gravity of the cerebral in- 
creased. 

Hysteria sometimes displays itself in 
connection with epilepsia mitior as well as 
in the grave form of hystero-epilepsia. It 
has been developed in my observation after 
diphtheria, scarlatina and rheumatism. In 
these instances I have always found a 
family history of this or other form of 
spasmodic neurosis. It is not uncommon 

*Clinique des Maladies du Systeme Nerveux, 
M. le Professeur Charcot pendant les annees 1889 
-90 et 1890-91 sous la direction de Georges Gui- 
non Chef de Clinique. Publications du Progres 
Medical. 

' ' Relation d'un cas type de maladie de Morvan 
complique d'hysterie. " Superposition des anes- 
thesies nysteriques et de Morvan chez le merne 
individu." 



140 



Correspondence. 



Vol. lxvii 



in ordinary chorea especially later in life 
after an earlier chorea, one of my present 
cases of chorea major shows hysteria mark- 
edly. But these are both ordinary func- 
tional nervous diseases. 

I think I have seen it in one instance 
brought out during the convalescence from 
hemiplegia as chorea sometimes appears. 

With these clinical facts before us, are 
we not justified in extending our search 
for hitherto unsuspected organic disease of 
the nervous system as causes of hysterical 
symptoms, as well as in looking to the 
womb for the fountain source of this symp- 
tomatic neurosis and in relegating to the 
back-ground the prevailing clinical dictum 
that, "Where hysterical symptoms present, 
the trouble is only a functional one of the 
nervous system?" - 

It is undoubtedly true, as Buzzard has 
clearly shown, that hysterical symptoms 
develop de novo only in part and as part 
of the expression of organic nervous dis- 
ease. I have seen such cases — cases where 
the mind was for quite awhile in doubt as 
to the real nature of the disease — whether 
organic or functional. As one may see 
paralysis appear and find the cincture feel- 
ing present and the knee jerks absent in 
hysteria sometimes, so may he see symp- 
toms of hysteria in real organic disease. I 
may note here a case of salam tremor or 
rhythmical contractions of the sterno-mas- 
toids, long suspected by myself to have 
been hyterical, which proved to have been 
caused by cervical pachymeningitis of 
which the patient subsequently died. 

As this is but a note of clinical warning 
we trust this word may prove sufficient to 
the wise clinician and with a brief quota- 
tion slightly qualified to compass our own 
view we close this paper as Buzzard has 
introduced his able address, our object 
being, " to draw attention to the frequency 
with which symptoms liable to be looked 
upon as (solely) hysterical are found to be 
really due to structural changes in the 
nervous system"' as the exciting if not 
solely causative factor. 



ANTIDOTE TO PHOSPHORUS. 

In cases of poisoning by phosphorus 
Bokai and Koranyi recommended a 1-5 to 
1-3 per cent, solution of potassium per- 
manganate. Brought in contact with this, 
the phosphorus is transformed into harm- 
less orthophosphoric acid. 



Correspon&ence* 



LETTER FBOM A SPECIAL CORRES- 
PONDENT. 



LONDON HOSPITALS AND WANT OF 
FUNDS. 

I find that London suffers from the 
same difficulties that we do in Philadel- 
phia, in spite of all its wealth ; namely the 
want of funds to sustain the hospitals. 
The various appeals which have been 
made by means of friends and the press, 
with concerts, flower-shows and all the 
ordinary measures to obtain sufficient 
means for sustaining them, have failed, 
and more recently they have adopted the 
Hospital Sunday Collection for which 
there was on the tenth day of June an ap- 
peal made by the various clergymen to 
their congregations for funds, yet, accord- 
ing to the London Times, the Hospital 
Sunday has not become the entire success 
which it promised to be in the begin- 
ning. 

It is stated that apparently, some people 
imagine that by giving on that day, they 
free themselves from the necessity of ex- 
tending further assistance to the associated 
physicians and surgeons. 

Each Hospital should receive a certain 
amount 'per capita/ or patient when they 
have been treated as an in-patient, and for 
out-door relief there should be a small 
sum paid by each patient for medicine, 
which, if judiciously employed, will almost 
entirely defray the expenses attending 
upon this class of cases. 

SALARIED RESIDENT HOSPITAL PHYSI- 
CIANS. 

Another subject has recently been dis- 
cussed by the medical press of England, 
namely, salaried hospital physicianship, 
owing to the difficulty of obtaining the 
services of a resident honorary physician. 
This is especially the case in agricultural 
districts, but it holds good in small hos- 
pitals in cities, especially in poor neighbor- 
hoods. It has been noticed that since the 
appointment of a salaried physician the 
income of the hospital (more especially at 
Colchester) has steadily increased and 
more than pays the thousand dollars 
salary. 



July 23, 1892. 



Selected Formulae. 



141 



The following statistics show the fluc- 
tuations in the hospital income and work 
for two years preceding, and the four years 
succeeding, the change : 





Hospital 
Saturday- 
Collections. 


Hospital 

Sunday 

Collections. 


Annual 

Subscriptions j 


Out-patients 1 
Fees, 1 s. per 
Letter.* 


Total Income 
of Hospital. 


Number of 
In-patients 
admitted. 


Number of 

Out-patients 

treated. 




£ 


£ 


£ 


£ s. 


£ 






1886 


468 


416 


918 


41 7 


2782 


! 531 


1535 


1887 


491 


409 


882 


35 19: 


2748 


! 503 


1418 




537 


406 


906 


50 4 


2847 


554 


1726 


1889 


568 


414 


905 


62 13| 


2882 


623 


1987 


1890 


606 


431 


919 


52 1 


2960 


585 


1814 


1891 


693 


451 


896 


56 2 


8179 


687 


1992 


t Increase since 


















202 


43 


14 


21 


431 


184 

1 


574 



—The Provincial Medical Journal, May 2d, 1892. 
EARXIl^GS OP DOCTORS INT ENGLAND. 

Mr. G-oschen, Chancellor of the Ex* 
chequer in 1892, drew a very roseate pict- 
ure of the earnings of professional men, 
lawyers and doctors, in England, when he 
compared the income derived from them 
with what he received with cotton spinners. 
Some of the lay papers have already drawn 
attention to the fallacy contained in his 
budget speech. As regards medicine, we 
need only say that it has been repeatedly 
proved that the income of the medical men 
does not exceed 200 pounds sterling, or 
$1000, a year, and out of this must he 
paid rent, taxes, rates, the expense of the 
household, of horse, carriage and groom, 
and all other items incidental to exist- 
ence. 

The money in each locality is returned 
to the butcher, baker, tailor and when the 
practitioner enjoys a larger income, he 
makes a much larger return to the commun- 
ity amongst which he lives in the increased 
style in which he lives. 

An income of $1000 a year, presuming 
that a medical man is married and has 
children, does not allow of extravagance 
in living. 

The moiety of income tax due upon that 
sum becomes a very great tax for the prac- 
titioner, and is one which he cannot well 
afford to pay. 

Lawrence Turnbull, M. D. 

London, England, June 12th, 1892. 

* One shilling is paid by each out-patient, on admission, 
the letter lasting three months. 

t The total increase, therefore, from the four first- 
named sources, is £279, so that after paying the phy- 
sician's salary a sum of about £80 comes into the general 
hospital funds from these sources. 



Selected formulae 



THE TREATMENT OF TAPE-WORM BY 
THE EXTRACT OF MALE FERN. 

The administration of male fern in the 
treatment of tape- worm is reviewed in the 
Province Medicale, No. 4, 1892, Journal 
de Medecine de Paris, May 1, 1892, as 
follows : — 

1. Crequy's prescription : 

T>, Extract of male fern 8.00 grammes. 

XV Calomtl 0.80 gramme. 

M. and put into eight capsules. Sig.— Two capsules 
every ten minutes. 

2. Peschier's formula: 

T>, Extract of male fern 3.50 grammes. 

XV Gum arabic .1.25 grammes. 

Powder of tin 1.25 grammes. 

Calomel 0.60 gramme. 

Medicinal soap . .0.60 gramme. 

Powder of fern root q. s. 

M. and make twenty pills. Sig.— Ten pills at ten 
o'clock at night, and the other ten an half hour after- 
wards. 

3. Madame buffer's formula: 

T> Powder of male fern 6.00 grammes. 

XV Water 125.00 grammes. 

M. Sig.— To be taken at once in the morning, before 
breakfast, to be followed one hour afterwards by a pur- 
gative, such as calomel or scammony. 

1. For children: 

TV Ethereal oil of male fern 0.50 to 1.00 gramme. 

XV Calomel 0.50 gramme. 

Water 15.00 grammes. 

Powdered sugar 15.00 grammes. 

Gelatine q. s. 

M. 

— Jour, de Medecine de Paris, Mav 1, 
1892. 

FOR CONSTIPATION. 

T>, Aloin. 134 centigrammes. 

XJe Extract of belladonna 6 milligrammes. 

Ipecacuahna 3 centigrammes. 

Strychnine 1 milligramme. 

M. and make one pill. Sig. — Night and morning 

— Jour, de Medecine de Paris, May 1, 
1892. 

IN CHLOROTIC DYSMENORRHEA. 

The following combination is recom- 
mended bv Monin (Jour, de Medecine de 
Paris, May 1, 1892) : 

T>, Tincture of balm-mint. 
XV Tincture of saffron. 

Tincture of iodine, of each 15 grammes. 

M. Sig.— Twelve drops before the principal meals. 
Every eighth day a warm bath, to which 125 grammes of 
chlorhydrate of ammonium should be added. 



ANALGESIC MIXTURE. 

As an analgesic combination the follow- 
ing is recommended (Jour, de Medecine 
de Paris, May 8, 1892) : 

T>, Menthol. 
XV Chloral. 

Camphor, of each 10.00 grammes. 

M. until liquefacation takes place. Sig.— Apply locally 
in toothache, rheumatism and neuralgia. 



142 



Selected Formulae. 



Vol. lxvii 



THE THERAPEUTIC USES OF CHLOR- 
HYDRATE OF AMMONIUM. 

In reviewing the therapeutic uses of 
chlorhydrate of ammonium, Oh. Liegeois 
{Rev. Gener. de Cliniq. et de Therapeu- 
tique, April 30, 1892) recommends the fol- 
lowing formulae : 

1. In convalescence of typhoid fever: 

TX Syrup of marshmallow 250.00 grammes. 

XX Syrup of squill 32.00 grammes. 

Ammoniated gum. 

Wine of antimony. 

Chlorhydrate of ammonia, of each, 8.00 grammes. 
M. Sig.— Several spoonfuls during the day. 

2. In Dysmenorrhea : 

L>. Chlorhydrate of ammonia 300.00 grammes. 

-M> Water 6.00 grammes. 

M. Sig.— A dessertspoonful, night and morning, be- 
fore the arrival of the period. 

3. In chronic pelvic peritonitis : 

T>, Chlorhydrate of ammonium 50 grammes. 

XX Simple syrup 500 grammes. 

M. Sig.— One to five dessertspoonfuls a day, taken at 
meal time, in a little water. 

4. As an antiperiodic : 

TX Powder of red cinchona bark. 

XX Chlorhydrate of ammonia, of each, 4.00 grammes. 

Syrup of puinpuina q. s. 

M. Sig.— One half to be taken immediately after the 
access, the other half six hours before. 



THE TREATMENT OF PRURITUS. 

The following combinations are recom- 
mended in the treatment of the different 
forms of pruritus {Jour, de Medecine de 
Paris, May 8, 1892):— 

1. Doyon's lotion: 

T> Oil of almond .500.00 grammes. 

XX Corrosive sublimate 0.20 gramme. 

Chloride of ammonium 0.25 gramme. 

M. 

2. Yidal's lotion: 

T>, Rose water 250.00 granur es. 

XX Hydrate of chloral 8.00 grammes. 

M. Sig.— After the lotion, some starch is applied. 

3. Hardy's ointment: 

73 Vaseline 20 00 grammes. 

XX Cyanide of potassium 0.10 gramme. 

M. 

4. Besnier's ointment : 

T>, Vaseline 30.00 grammes. 

XX Cocaine 0.30 gramme. 

M. 

5. In pruritus of pregnancy : 

T>, Warm peppermint water 1 glassful. 

XX Borax 4.00 grammes. 

Essence of allspice 5 drops. 

M. Sig.— Apply with a soft sponge. 

6. In eczematous vulvar pruritus: 

T>, Olive oil 30.00 grammes. 

XX Iodoform 0.25 gramme. 

M. Sig.— Locally applied. 



7. Persy's formula : 

T). Phenic acid 1.30 grammes. 

XX Tincture of opium 15.00 grammes. 

Hydrocyanic acid 7.50 grammes. 

Glycerine 15.00 grammes. 

Distilled water 120.00 grammes. 

M. 

8. P. Menier's formula: 

T>. Pulverized talc 15.00 grammes. 

XX Bichloride of mercury 0.50 grammes. 

Dried extract of valerian 2.00 grammes. 

M. Sig. — Apply twice or three times a day. 



RESECTION OF THE OS CALCIS AND 
ASTRAGALUS. 

Dr. Bogdanik describes the following 
procedure: The operator stands on the 
right side of the patient, and makes an 
incision beginning closely beneath the ex- 
ternal malleolus, if the operation is per- 
formed on the left foot, but beneath the 
internal malleolus if on the right. The 
incision penetrates to the calcaneum and ex- 
tends obliquely downwards and backwards, 
in the direction of the annular ligament 
and at a distance of one centimetre from 
the sole of the foot, toward the other mal- 
leolus. The calcaneus is sawed through 
in the same direction, while the foot is 
pressed by an assistant against the leg. 
As soon as the bone has been divided the 
foot can be readily folded back, so that 
the dorsum is in contact with the anterior 
surface of the leg, permitting an inspec- 
tion of the ankle joint. The astragalus 
can now be grasped with bone forceps and 
removed with knife and scissors. It is of 
advantage to prolong the incision over 
both malleoli in the direction of the tendo 
Achilles, because this enabled us to draw 
upward the upper portion of the calcaneus. 
It is further advisable to retract the arter- 
ies and tendon with blunt hooks so as to 
prevent their injury by the knife. If the 
calcaneus is diseased the affected portion 
may be chiselled out, curetted, or, if neces- 
sary, the entire bone may be removed. 
After the removal of the astragalus the 
articular surface of the tibia and fibula 
can be readily brought into view. 

The author has performed this opera- 
tion on two patients and claims for it the 
following advantages : 

1. The incision in the soft parts is 
small. 

2. Injury of the vessels, tendons, mus- 
cles or nerves is avoided. 

3. The situation of the scar is favorable. 

4. Configuration of the foot is preserved. 
—Centralbl. f. Chirurgie, No. 3, 1892. 



July 23, 1892. 



Editorial. 



143 



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XeabinQ articles. 



THE THERAPY OF ABORTION. 

There is considerable difference of opin- 
ion upon many points regarding the ther- 
apy in cases of abortion where part or all 
the foetal matter is retained within the 
uterus. While Winckel and other au- 
thorities both in this country and abroad 
suggest in such cases in which there is no 
fever, putrid discharge or haemorrhage an 
expectant treatment, on the other hand 
Schrceder, Olshausen, Fritch, Yeit and 
many others lay great stress upon the 
necessity of the immediate removal of the 
ovum and decidua. An important paper 
on this subject has appeared from the pen 
of Dr. Kuppenheim in the Deutsche mecl. 
Wochenschrift. He reports the results 
obtained and the therapy used in 84 cases 
of abortion treated in the Women's Clinic 
of Heidelberg, and his article has been 
discussed editorially in a recent issue of 
the Medicinische Neuigheiten. 

The course of seven cases out of these 
eighty-four cannot properly be taken into 
consideration, as only a single rise of tem- 
perature to 38° and 39° C. characterized - 
an unusual condition of the patients. In 
seven other cases the patients when they 
came for treatment already had high fever, 
and were severely ill in consequence of the 
delay of proper treatment; one, indeed 
dying from sepsis. In these eighty-four 
cases digital removal of the ovum and de- 
cidua was practiced thirty-two times, and 
the curette was used in fifty- two cases. 
Three out of the first group and four out 
of the second succumbed. 

Prior to the digital removal, the 
vagina, cervical canal, and if possible the 
uterus, should be syringed or washed out 
with a proper antiseptic solution such 
as a three per cent, carbolic acid solution 
or a 0.25 per cent, solution of bichloride 
or mercury, and a similar washing should 
be pursued after the operation. 



144 



Editorial. 



Vol. lxvii 



The curette was used in cases of retained 
ovum in the second and third months of 
pregnancy, and only in the later months 
when after the digital removal of the ovum 
a retention of a portion of thedecidua was 
suspected. The curette was always used 
with the patient in the Sim's position, after 
careful disinfection of the parts, and with- 
out anaesthesia. Recumier's curette was gen- 
erally employed. The remnants of the 
decidua are scraped away with the curette 
in closely-lying parallel lines, care being 
taken not to injure the entrances of the 
tubes. Especially during the first three 
months of pregnancy, when the narrowness 
of the cervix precluded the possibility of 
digital removal without dilatation of the 
cervix, the operation of curetting is pre- 
eminently adapted for this purpose. In 
many cases, even after the digital opera- 
tion has been sucessfully carried out, the 
curette will bring away shreds of mem- 
brane, and it is very often these that cause 
the most severe haemorrhages. As a most 
important advantage of the curette, Kup- 
perheim speaks of the fact that for its use 
the cervix need not be dilated. Another 
advantage is that its use causes but very 
little pain, so that the operation can 
safely be undertaken without anaesthesia. 
Kuppenheim is of the opinion that the 
•danger of perforating the uterus by the 
curette is decidedly exaggerated by the 
nlajority of gynaecologists. 

Regarding the other therapeutic means 
employed, we must mention that of cau- 
terization with a ninety-five per cent, solu- 
tion of carbolic acid. This was used by 
Kuppenheim in all cases that came to the 
clinic in a state of infection. The carbolic 
acid is applied by a sound with a pledget 
of- cotton wrapped on the end, or with a 
piece of cotton held in a polypus forceps. 
The results of this treatment were, that in 
six cases the fever fell at once, and in one 
case a pelveo-peritonitis ceased. The cau- 
terization' with carbolic acid has other ad- 
vantages, it stimulates uterine contractions 



and acts beneficially in checking existing 
endometritis. 

For the checking of haemorrhage conse- 
cutive to abortion, Dilhrssen's application 
of chloride of iron has long occupied a 
position of prominence ; the iodoform gauze 
tampon will, however, usually be found of 
greater service. 

The after-treatment consists besides a 
confinement to the bed for eight days, in 
vaginal douches and the administration of 
ergot. 

Briefly summed up, Kuppenheinr's be- 
lief is that during the first three months 
of pregnancy the foetal remains should be 
removed manually and with the curette; 
that in the later months the manual 
method alone may often prove efficient in 
itself, and that the placenta should always 
be removed manually, but fragments of the 
same can only successfully be removed with 
the curette. 

APPLICATIONS OF COLD IX TRAU- 
MATIC SURGERY. 

"It is to be regretted," says Dr. Buch, 
in a recent number of the St. Peterslurger 
med. Wochenschrift, "that while we are 
fully aware of the valuable properties of 
cold applications in allaying pain and in- 
flammation, yet we believe ourselves un- 
able to apply it in the very instance where 
it would prove most useful." Dr. Buch 
refers to those cases in which the affected 
parts are covered with an antiseptic dress- 
ing or plaster of Paris bandage, and in 
which the local dressings hinder a direct 
cooling of the part. 

According to Buch's experiences the 
procedure suggested some time ago by 
Winternitz is far too little known, and 
even to a less extent adopted. It consists 
in a method of cooling the affected limb 
without necessitating the removal of either 
dressing or plaster of Paris bandage, and 
is. especially applicable when the injury is 
in the lower half of : the extremity. 

Winternitz's experiments have conclu- 



July 23, 1892. 



Editorial. 



145 



sively demonstrated that if the upper part 
of an extremity be surrounded with ice, 
the blood-vessels of the entire limb con- 
tract. Winternitz explains this effect by 
a direct action on the vessels, and upon 
the nerve branches. Buch, however, as- 
cribes the result to a reflex action, for 
it frequently suffices to place a single piece 
of ice upon any portion of the upper part 
of the arm to affect the temperature of 
the entire arm several degrees. 

Winternitz did not fail to recognize the 
practical value of his discovery and in- 
variably used ice applications as described 
in connection with the local dressings, 
and found that by so doing he was able to 
completely check the inflammation in the 
parts. The method has not, however, re- 
ceived the attention it deserves. Buch 
has, where possible, used the central ap- 
plications of cold in connection with the 
local, and has obtained, thereby, far more 
gratifying results than when only local 
applications were employed. But in other 
cases, as has been mentioned, where a 
permanent or fixed bandage precludes the 
direct use of cold, the application above 
the dressing then of course is the only one 
feasible. Buch has obtained the most 
brilliant results for the past few years in 
this way. Since he adopted it he has 
been able to keep iodoform dressings in 
their place which otherwise on account of 
the pain they produced would have had to 
be removed. As soon as the wound began 
to be painful, Buch would apply a cold 
pack, or if possible an ice-pack, above the 
dressing, and found that invariably within 
a short time the pain would cease, and 
discovered that by this means he could 
guide the reaction of the wound at will. 

The same holds good for fractures of 
the extremities. Buch is positive that in 
many cases the plaster of Paris splint was 
well-endured solely on account of the 
presence of the cold above the wound. 
During the preparation of the splint he 
applied extremely cold applications to the 



entire limb in order to reduce the tem- 
perature of the parts as much as possible, 
and as soon as the bandage has been ap- 
plied, continues these applications above 
the bandage. In any case, as soon as the 
plaster splint causes pain, he applies an ice- 
pack above the splint, whereby he has 
always been able to control the pain and, 
in connection with an elevated position of 
the limb, also prevent the dangerous 
swelling so often seen. 

Buch also lays stress upon the technique 
of this method, and agrees with Winter- 
nitz that wet cold is much more efficient 
"than dry cold. Therefore, if the ice-bag 
is used it should not be placed dry upon 
the skin, but laid upon a wet compress. 

It does seem strange that a method so 
simple and efficient should not have had 
the universal adoption it deserves. The 
use of cold in surgery and medicine will 
unquestionably be one of the important 
therapeutic measures of the future. 



ON NYSTAGMUS IN AFFECTIONS OF 
THE EAR 

Dr. Michael Cohn has observed four 
cases of nystagmus occurring during the 
course of aural diseases. In Case 7, of 
purulent otitis media, the nystagmus was 
easily produced by the external or internal 
douche, or even by slight pressure on the 
tragus of the diseased ear. If a plug of 
cotton was inserted, pressure on the tra- 
gus did not produce the nystagmus, which 
was horizontal in character and accompan- 
ied by vertigo. The purulent discharge 
soon ceased, but the nystagmus kept on. 
After electrical treatment it soon disap- 
peared, although the discharge reappeared. 
In Case 77, the nystagmus and vertigo 
were produced by injection of warm solu- 
tions. Vertigo also appeared on hearing 
music. In Cases III and IV it was 
caused by the injections of cool solutions. 
After a discussion of the various theories 
proposed, the author reaches the conclu- 
sion that attacks are most probably caused 
by an irritation of the semi-circular canals, 
rather than by a direct irritation of the 
brain. — Berlin Klin. WocJiensch., No -43, 
1891. 



146 



Book Reviews — Periscope. 



Vol. lxvii 



Book Reviews. 



PRACTICAL MIDWIFERY. A Hand-book of 
Treatment. By Edward Reynolds. Fellow 
of the American Gynaecological Society, of the 
Obstetric Society of Boston, etc. Assistant in 
in Obstetrics in Harvard University, etc., etc., 
8vo, 424 pp.. 121 illustrations. New York: 
Wm. Wood & Co. Price, $2.50. 

Few men are better qualified to compile 
a manual of practical midwifery than the 
author of this well- written treatise upon 
the management of labor and the after- 
treatment of the woman; for he has 
brought to the task the learning of a large 
experience and the capacity to well-express 
his thoughts. 

The author does not intend the work to. 
be anything more than a practical manual 
of the practice of midwifery, wholly in ac- 
cord with our latest ideas on the subject. 

The arrangement of the volume is largely 
a natural one in dealing with obstetrical 
medicine, the parts of the book being ar- 
ranged as follows: pregnancy, normal 
labor, obstetrical surgery, abnormal labor, 
the pathology of labor, and the puerper- 
ium. The chapters are grouped under the 
above headings, so that as a useful ready- 
reference book it will prove of much value 
to the busy worker. The first chapter 
enumerates briefly and clearly the essential 
facts concerned in the diagnosis of preg- 
nancy. Following this the functional dis- 
orders of pregnancy and the care of normal 
pregnancy are considered, this being suc- 
ceeded by a chapter on normal labor. All 
discussion of theoretic knowledge is rigidly 
avoided, and the chief usefulness of the 
book is in this very fact, which has re- 
sulted in the production of a manual con- 
taining simply the best and most modern 
ideas upon the subject of midwifery and 
surgical obstetrics. 

The illustrations deserve mention: in 
general they are very good and clearly il- 
lustrate the points needing emphasis in a 
work of this character. 

We predict for this admirable manual a 
most cordial reception. 



CEREBRAL SCLEROSIS, OF SPECIFIC 
ORIGIN. 

Prof. De Costa prescribed : 

K Potassii iodidi .....gr. x. 

Hydrarg. bichloridi . gr. 1-40. 

Syrup, sarsaparillae. 
Aquae, aa ad. f5j.— M. 
Sig.— Three times a day. 



periscope* 



THERAPEUTICS. 



ACTION OF OZONE ON THE ORGANISM. 

Observers are now agreed in regarding 
the effects of oxygen on the system as due 
to its partial transformation into ozone. 
MM. Labbe and Oudin have concluded a 
series of interesting experiments bearing 
upon the physiological action of the latter 
substance. They found that ozone in- 
creases the amount of haemoglobin in the 
blood by about 1 per cent. This increase 
is chiefly in the case of anaemic subjects, 
whose olood contains only 10 or 11 per 
cent, of haemoglobin ; individuals having a 
normal proportion of the latter, 13 to 14 
per cent, are unaffected by treatment by 
oxone. 



TREATMENT OF ATHEROMATA. 

Lutz (Monatsheft. f. praJc. Dermat. No, 
12., Vol. XIII, 1891.) recommends that 
atheromata, which have suppurated and 
those which are thin-walled and very ad- 
herent, should be treated by incision, the 
contents are evacuated, the cavity lightly 
scraped with a curette and then painted 
with tincture of iodine. He had wonder- 
fully good results and found it much easier 
and satisfactory than the treatment by 
excision. 



ANTIPYRIN IN INCONTINENCE OF 
URINE. 

In a thesis on this subject, Dr. Gaudez 
has shown the good effects obtained from 
the use of antipyrin in cases of idiopathic 
incontinence of urine in children. The 
author reports 29 cases — 14 children com- 
pletely cured, 12 improved, and 3 unre- 
lieved. 

The antipyrin is given either in cachets 
or in solution, but in either case a small 
quantity of soda bicarbonate is added to 
each dose. The dose of antipyrin varies 
from 1.50 to 4.00 grammes (22 to 60 
grains), according to the age of the child. 
These doses are given in the following way: 
0.50 to 1.00 gramme (7}4 to 15 grains) at 
6 o'clock in the evening; a second dose at 
8 o'clock, when the child goes to sleep. 

M. Gaudez insists strongly on the hours 
at which the medicine is given. Some- 
times, if the last dose is given at 8 P. M. , 
the child may have involuntary micturi- 



July 23, 1892. 



Periscope, 



147 



tion about 5 A. M. ; but if the last dose is 
given from 9 P. M. to 11 P. M., the in- 
continence disappears entirely. 

These good results of antipyrin have 
been observed very often from the first 
day of its use; it is not generally necessary 
to continue the treatment with antipyrin 
longer than a fortnight to obtain a per- 
manent cure. — Gazette des Hopitaux, 
November 17, 1891, p. 1238. 



THERAPEUTIC USES OF METHYLENE 
BLUE. 

Constantin Paul (Sem. Med., December 
30th, 1891) says Desnos's experiments with 
methylene blue in cases of locomotor ataxy 
have shown that patients can without incon- 
venience take as much as 30 centigrammes 
of the drug daily, and that even when it 
was given in smaller doses the urine was 
intensely colored. 0. Paul himself found 
that a dose of 10 centigrammes colored the 
urine till the third day. After a dose of 
5 centigrammes the urine was still colored 
on the following day, and even to a slight 
degree on the day after. Gradually lessen- 
ing the dose, he found that after 2 centi- 
grammes the urine was distinctly colored, 
and had not entirely regained its normal 
appearance the next day. Methylene blue 
being absolutely harmless, 0. Paul thinks 
its administration affords a reliable means 
of satisfying oneself whether patients are 
taking the remedies prescribed for them, 
which may be of practical use in prisons, 
lunatic asylums, etc. He further hints 
that the drug may also be employed by way 
of " suggestion" in order to convince neu- 
rotic patients of the efficacy of the treat- 
ment which they are undergoing, and as a 
useful placebo when the practitioner wishes 
to try the expectant method without taking 
the patient or his friends into his confi- 
dence. — Brit. Med. Jour. 



ON THE EFFECTS OF CHLOROFORM. 

L. E. Shaw, M. D., (British Medical 
Journal, November 21, 1891.) gives an ac- 
count of some experiments made by Dr. 
Gaskell and himself which were in accord- 
ance with those of the Hyderabad Commis- 
sion. They show that when chloroform 
is administered without interfering with 
perfectly regular respiration, complete in- 
sensibility can be produced without obvious 
weakening of the heart's beat. Inefficiency 



of the heart is brought about by the rapid 
inhalation of chloroform m too concentrat- 
ed a form. The practical teachings are 
that it should be administered slowly, and 
with plenty of air, and that great care 
should be taken not to push the chloro- 
form when struggling or gasping respira- 
tion occurs. 



AN AROMATIC CASTOR OIL. 

Dr. Standke (Norsk Magazin for 
Lcegevinenskaben, No. 3, 1892) proposes 
the following manner of preparing an aro- 
matic and well tasting castor oil: 

The best oil is treated with warm water 
several times and saccharin added. This 
gives a sweet-tasting syrup, which will 
keep as long as the original oil. If now 
small quantities of oil of cinnamon and the 
essence of vanilla be added the last remain- 
ing traces of harshness will disappear. 



PIPERAZIN. 

This substance in aqueous solution dis- 
solves twelve times as much uric acid as is 
dissolved by the same quantity of carbon- 
ate of lithium. There is formed a neutral 
urate of piperazin, which is seven times as 
soluble as urate of lithium. Piperazin it- 
self and also the hydrochlorate are easily 
soluble in water. The dose is from fifteen 
to forty-five grains a day. It may be pre- 
scribed as follows : 

TD. Piperazin gr. xv. 

-TV Aquae destll 3 vi. 

Syrup Aurant cort 5 v. M. 

Sig.— To be taken in the course of the day. To be in- 
creased gradually. 



TREATMENT OF TUBERCULOUS DISEASE 
OF THE KNEE. 

Drobnik (Centrab.f. Chir., No. 11, 
1892.) advocates free exposure of the in- 
terior of the tuberculous cavity, and long- 
continued plugging with iodoform gauze 
as an efficient method of treatment in 
cases of tuberculosis of the knee, in which 
both arthrectomy and resection are contra- 
indicated, and no alternative remains save 
amputation of the limb. The author holds 
that in all cases of tuberculous disease 
amenable to surgical treatment, the seat 
of the disease should be freely exposed and 
kept open in order to enable the organism 
to reject the tissues already destroyed or 
undergoing necrosis. Free exposure of the 
tuberculous deposit is followed by a pro- 
fuse secretion of fluid from the diseased 



148 



Periscope. 



Vol. lxvii 



tissues, which drives away the necrosed 
parts from the immediate neighborhood of 
the wound, and at the same time estab- 
lishes in the surrounding tissues increased 
vital energy, and a more energetic resist- 
ance to the attacks of the morbid agents. 
This discharge continues until the inner 
surface of the exposed cavity is lined by a 
thick layer of healthy granulations. In 
cases in which there are two or more cavi- 
ties near the joint, the author would make 
a large opening into each. This method 
is indicated only in cases of osteal tuber- 
culosis of the knee-joint, and in those in 
which progressive and destructive disease 
of the bone necessitates surgical interfer- 
ence. Cases of primary synovial tuber- 
culosis, and of secondary synovial infection 
in consequence of the communication with 
the joint of one or more small osseous 
cavities, are best treated, after the failure 
of conservative measures — such as exten- 
sion, rest in splints, and injections — by 
arthrectomy. — British Medical Journal. 

GLYCERIN SUPPOSITORIES WITH BORIC 
ACID. 

The use of boric acid as a laxative, when 
introduced into the rectum, having re- 
cently been advocated, Mr Peter Boa 
thought of employing the Glycerinum 
Boracis of the British Pharmacopoeia. For 
the. purpose of comparison he made two 
sets of 15-gr. suppositories, one with 
glycerin alone, and the other with glycerin 
(or as we say, glycerite) of borax. They 
were tried practically, and the reports 
(according to the Chem. and Drugg.) were 
distinctly in favor of those containing 
boric acid. The simple glycerin suppo- 
sitories either failed to act at all or acted 
only very slightly, while those containing 
boric acid acted in some cases as efficiently 
as large glycerin suppositories, requiring 
however , a longer time. 

A NEW REMEDY FOR RHEUMATISM. 

At a recent meeting of the Berlin Medi- 
cal Society, Dr. Paul Guttman recom- 
mended a new medicament called salophen. 
It is a finely crystalline [substance, easily 
soluble in ether and in alcohol, but not 
soluble in water. It consist of salicylic 
acid and acetylparamidophenol in almost 
equal parts. Six to eight grammes can 
be given daily without injury to the 
patient. It has a slight anti-febrile 
effect. — The Lancet. 



THE RELIEF OF VOMITING. 
Kenny. {British Medical Journal, 
No. 1618, p. 16) has reported the case of 
a parturient woman, in whom he overcame 
obstinate vomiting, resistant to other 
means of treatment, by the application of 
a cantharidal blister over each pneumo- 
gastric nerve at the anterior border of the 
sterno-mastoid muscle. 



COLOMBO IN THE CONVALESCENCE OF 
INFLUENZA. 

An anonymous correspondent of Le 
Progres Medical, of Paris, warmly recom- 
mends the use of Colombo as a tonic and 
sedative in the convalescence of the grippe. 
The writer has found it to be an incom- 
parable preventative and curative remedy 
in the gastric and pulmonary forms of 
this disease during the last two epidemics. 
The powder, decoction or an elixer may be 
prescribed. It causes the appetite to re- 
turn, the. vomiting to cease, and the stools 
to become regular, while the convalescence 
is comparatively short and insignificant. 



MORPHINE AND ATROPINE. 

Stickler (CentralM. f. hlin. Med., 
March 26th, 1892) says that in cases of 
poisoning, the antagonism of these drugs 
cannot be doubted, and that the want of 
general recognition of the fact is due to^ 
the few opportunities of observing it. The 
unpleasant eifects of morphine used as a 
hypnotic may be prevented by the addi- 
tion of atropine. In some cases morphine 
produces excitement, and if it will be still 
necessary to use it, atropine will antago- 
nize this. . A subcutaneous injection of 
morphine lessens considerably the dilata- 
tion of the pupil produced by atropine 
drops, and an injection of morphine and 
atropine combined produces only slight 
dilatation of the pupil. Irritation of the 
skin sometimes produced by morphine is 
prevented by atropine. The diaphoretic 
effects of morphine are sometimes trouble- 
some; they do not occur if atropine be 
added. On the other hand, the dryness 
of the skin produced by atropine is rem- 
edied by morphine. One of the effects of 
morphine sometimes seen, and especially 
in those with early paralysis of the bladder, 
as in tabes, is retention of urine. Bella- 
donna antagonizes it. Morphine mostly 
constipates; atropine has the opposite 
effect, especially in chronic constipation. 



July 23, 1892. 



Periscope. 



149 



In biliary and renal colic the two drugs superior to digitalis in that it does not 

should be combined, as not only is any ob- have a cumulative action, is not adepress- 

.struction to the passage of the stone less- ant, nor does it give rise to digestive dis- 

ened, but the power of propelling the turbances. Its chief value seems to be in 

stone is increased. In cases of heart dis- the nervous affections (erethism) of the 

ease with engorged pulmonary circulation, heart, whether primary, or secondary to a 

morphine is badly borne, whereas the ad- general neurosis, particularly in cardiac 

dition of a small quantity of atropine does disturbances due to excess in venery, 

away with any disadvantages. — Brit. Med. tobacco, coffee, or alcohol. — Amr. Jour. 

Jour. Med. Set. 



POISONING BY PILOCARPINE. 

A Belgian officer, with an affection of 
the eyes, was treated by the injection of 2 
centigrammes (}§ grain) of this drug. 
Immediately his neck, and then the whole 
of the body, became bathed with sweat; 
in two or three minutes he was salivated, 
and suffered from cardiac oppression and 
difficulty of breathing; he fancied his 
chest was full of fluid, and afterward he 
expectorated some frothy mucus. The 
cardiac oppression lasted about ten min- 
utes, but for two hours the patient con- 
tinued to have a feeling of constriction at 
the pit of the stomach. During this time 
he suffered from lachrymation, running 
from the nose, gastralgia, and nausea; he 
vomited three times, and passed his urine 
involuntarily. The intestinal peristalsis 
became violent, and he had tenesmus. 
His eyes were fixed, and he could not rec- 
ognize any one twenty centimetres (eight 
inches) distant. The pulse was quick and 
small, the sufferer being in a condition 
bordering on collapse. By means of inter- 
nal and external stimulants the symptoms 
disappeared. — The Lancet, February 6, 
1892, p. 329. 



CORONILLA. 

M. V. Poulet (Bulletin General de 
Therapeutique, 1891, No. 46, p. 481) 
gives the result of his studies. The tinct- 
ure of the entire plant was used in daily 
dosage of from one to two and a half 
drachms, believing that it was valuable 
in paroxysmal tachycardia, in the painful 
phenomena of certain reflex cardiopathies, 
in the disorders occasioned by changes at 
the aortic orifice; it relieves the symptoms 
due to lesions of the mitral valve; that it 
cuts short, frequently in a remarkable 
manner, the attacks of cardiac or bronch- 
ial asthma, it increases the appetite; is a 
tonic so far as the alimentary canal and 
general system are concerned. It is 



NERVOUS SYMPTOMS FOLLOWING THE 
USE OF QUININE. 

Dr. A. Erlenmeyer reports (CentralU. 
f. Nervenheilk), a case of poisoning by 
quinine which seems to be of some inter- 
est. Previous to this writing the author 
had observed abolition of the reflexes in 
several patients who were taking large do- 
ses of quinine, but in the case under con- 
sideration the symptoms were of an intense 
reflex irritability. The patient, aged for- 
ty-two years, had taken at one dose 1,0 of 
the drug, on the following day 2,0, in 
broken doses, examination of the patellar 
reflex at this time, by tapping and so forth, 
brought on a series of general convulsions 
with violent contractions of the arms and 
the whole body. On leaving off the medi- 
cament for twenty-four hours the nervous 
excitability would entirely disappear. 



DIETETIC TREATMENT OF CARDIAC 
DISEASE. 

Hirschfeld (Berl. klin. Woch., March 
4th, 1892) says that in the corpulent the 
diminution of fat, along with diminished 
weight, is accompanied by a considerable 
loss in albumins. All cures for obesity 
consist in diminished nutrition. In spite 
of this, certain organs gain in working- 
power, as is also illustrated by the hyper- 
trophied sterno-mastoid muscles in phthi- 
sis. In ordinary people, as in the corpu- 
lent, the heart muscle under such condi- 
tions maintains, or even increases, its 
working power. In diminished nutrition 
the total amount of blood is lessened. On 
the other hand, by the absorption of dis- 
solved food stuffs into the circulation more 
fluid has to be driven by the heart. 
Again, when food is taken there is an in- 
creased consumption of oxygen by the 
glands, etc., and therefore more blood has 
to be sent to the organs in question. 
Thus, with a lessened supply of food, the 
amount of work to be done by the heart is 



150 



Periscope. 



Vol. lxvii 



diminished, and at the same time its work- 
ing power is not affected. If a valvular 
defect arise after rheumatism the reserve 
power of the heart is called upon before 
compensation is established. A limitation 
of diet is here certainly correct. It is 
more difficult to decide upon the value of 
this limitation in disturbance of compen- 
sation. The undoubted value of the milk 
cure is in the author's opinion due to lim- 
ited supply of food. Touching upon the 
subject of strengthening the heart by mus- 
cular activity, Hirschfeld points out that 
the latter should be increased but gradu- 
ually, and that the Marienbad cure as us- 
ually practiced requires of the heart too 
great exertion in too short a time. This 
over- exertion may predispose to dilatation. 
— Brit Med. Jour. 



SALICYLATED COLLODION FOR THE 
ITCH 

This has been found exceedingly satis- 
factory, according to a report of A. S. 
Rauschenberg in the Pharmaceutical Rec- 
ord. The treatment in seven cases con- 
sisted in first ordering a hot alkaline bath, 
to remove all grease from the skin, and 
then to apply to each spot where the dis- 
ease showed itself a coating of the N. F. 
salicylated collodion, i. e., the ordinary 
corn cure. Each night the patient was ex- 
amined for new spots, which were carefully 
painted as well as all those places in which 
the covering had become injured. The 
cure is completed within ten days. The 
advantages of this treatment are : immedi- 
ate cessation of pain (the first application 
causes transient smarting), simplicity and 
cleanliness. 



CEREBELLAR TUMOR. 
Dr. Howard publishes in the Austral- 
ian Medical Journal the case of a patient 
who had been under his care suffering 
from cerebellar tumor. The patient was 
a woman of forty, who for six months 
before her confinement in December had 
suffered from headache, giddiness, and 
unsteadiness in walking. Her symptoms 
became aggravated after her confinement; 
she staggered in walking, being inclined 
to fall to the left side. She had severe 
headache, worse in the occipital region to 
to the right of the middle line. There 
was no actual paralysis, her knee-jerks 



were normal, and there was no change in 
the optic discs and fundi except some 
venous engorgement. Death took place 
suddenly, and at the necropsy a round 
tumor was found arising from the back 
of the inferior vermiform process of the 
cerebellum, and growing forward so as to 
fill all the front part of the fourth ventricle. 
The tumor was an inch and three-quarters 
long and an inch and a half broad, and in 
structure was a mixture of glioma and 
sarcoma. — Lancet. 



NUCLEO-ALBUMINE IN THE URINE. 

Dr. Obermayer, in a lecture given 
before the "Gessellschaft der Aertze," re- 
viewed the different forms of albumin, 
among which mucus was formerly desig- 
nated, generally as an albuminate. Ac- 
cording to its reaction and behavior with 
acetic acid, it has been more recently 
classed as an uncrystalline body allied to 
the proteids, forming a group which is 
easily precipitated by acetic acid, whose 
members are mucine, nucleine, nucleo- 
albumine,etc. Mucine and nucleo-alb Limine 
have been frequently found in the urine, 
but nuclein is invariably absent. Ober- 
mayer asked himself if the presence of nuc- 
leo-albumine was the result of morbid 
changes in the kidneys. With this ques- 
tion before his mind he had examined six 
cases of leukaemia in Prof. JSTothnagel's 
clinic, and found nucleo-albumine in each 
case. In thirty-two cases of icterus that 
he examined, nucleo-albumine was present ; 
in other diseases where the kidneys were 
affected or irritated by the use of irritants, 
such as sublimate, naphthol, pyrogallol, 
etc. , as well as diphtheria, where it was 
found in a very large quantity ; in scarlati- 
nal nephritis and other acute forms of 
morbus Brightii, none or scarcely a trace 
was to be found. 

In cystitis it was also found in consi- 
derable quantity. These results raised 
the question of a morbid origin, which 
Obermayer has divided into vesicular and 
renal nucleo-albuminuria, but leaves it 
questionable whether the latter is haema- 
togenous or inogenous. He considers the 
renal nucleo-albuminuria is the result of 
injury to the renal epithelia, and more 
particularly that of the medullary, which is 
of clinical importance and may be found 
to possess diagnostic method. 



July 23, 1892. 



Periscope. 



151 



THE RECENT EPIDEMIC OF INFLUENZA 
IN BERLIN. 

Eenvers (Deutclie medicinische Wochen- 
schrift, Dec. 17, 1891) states that the 
first * epidemic of influenza reached its 
height in Berlin at the end of December, 
1889. Since January, 1890, the epidemic 
influenza has been absent from Berlin, 
though there was always the temptation to 
call every severe catarrh influenza. Dur- 
ing 1890 and 1891, there seemed to be a 
special tendency to catarrhal affections 
throughout the city. At the end of Octo- 
ber, 1891, the writer observed the first 
typical attack of influenza again. The 
epidemic has developed complications in 
persons troubled with heart and kidney af- 
fections, and the prognosis is grave in 
such cases. In young children there ap- 
pears to be an early appearance of heart 
weakness. Lung complications are very 
frequent. Since November 7, there were 
twelve cases of inflammation of the lungs, 
four of typical croupous pneumonia, and 
four or five of catarrhal pneumonia. In 
these there is but little dullness, usually a 
rapid disappearance of the fever. The 
sputum is tenacious and expectorated only 
with the greatest difficulty. He thinks 
that true pneumonia rarely appears, but 
the influenza catarrh gives a starting-point 
for all sorts of secondary infections of the 
lung alveoli. Influenza can also cause 
death through capillary bronchitis. There 
were also severe nervous complications 
during the epidemic. In a great part the 
epidemic resembles that of former years. 
He believes that the influenza is both in- 
fectious and contagious. — Univ. Med. 
Mag. 



RETINAL BLOODVESSELS. 

Dr. James Musgrove gives an account 
in the last number of the Journal of Anat- 
omy and Physiology of a method of prepar- 
ing the retinal vessels for demonstration 
either with the naked eye or with the lan- 
tern. His observations were carried out 
on the eye of the ox, but his method is 
equally applicable to that of other animals 
or of man. In the case of the ox the in- 
jection can be made quite well after the 
eye has been removed from the orbit. As 
much as possible of orbital fat and tissue 
should be removed with the eye-ball, and 
the vessels are to be cut far away. The 
injection is made through the ophthalmic 



artery with a hand syringe, and the eye 
should be kept in hot water for half an 
hour before the injection is made. When 
the injection is completed the eye is al- 
lowed to cool for two or three hours to al- 
low the gelatine in the injection to set. 
The entire retina is then removed by cut- 
ting through the cornea and iris and re- 
moving the lens and vitreous. The retina 
is then found hanging down from the op- 
tic disc, and its attachment there is divided 
with a knife. The entire retina may thus 
be freed and floated out on water, and it 
is then spread out, with considerable trou- 
ble it is true, on glass by means of a small 
camel-hair pencil. The specimen is then 
dehydrated and clarified in oil of cloves, 
after which balsam dissolved in benzol is 
spread over it, and another thin lantern 
slide used as a cover glass. In this way 
the retinal vessels can be clearly demon- 
strated, and Dr. Musgrove gives a short 
account of their distribution, in which he 
found a remarkable uniformity in the dif- 
ferent retinas examined. — Lancet. 



AN UNUSUAL NEUROSIS. 

An interesting case of an unusual neu- 
rosis has been recorded in a foreign con- 
temporary. The patient was a teacher, 
intelligent, unmarried, aged 25, w T ith no 
neurotic family history. Menstruation 
was regular in time, but protracted in du- 
ration, and always accompanied with pain. 
One day her left eye was injured by a 
broken violin string, and as the result of 
this it was noticed that reading readily 
caused annoyance. On examination no 
lesion of the eye could be detected. There 
was considerable headache. Soon after- 
wards it was observed that on excitement 
or emotion the left half of the face flushed 
and became warm, and in the course of 
two or three seconds the left side of the 
face and head became the seat of profuse 
perspiration ; the left ear became purple, 
and from the auditory canal there flowed 
an aqueous discharge. A sense of fullness 
was also felt in the left nostril. At the 
same time the right side of the face be- 
came pale, dry, and cold. If the proro- 
cation was intense, the left arm up to the 
elbow-joint became red, but without per- 
spiration. The phenomena were aggravat- 
ed during menstruation. Improvement 
took place as menstruation was regulated, 
and when the constipation, which was 



152 



Periscope. 



Vol. lxvii 



troublesome was relieved. Iron and aloes 
were the means by which a cure was effec- 
ted. — Medical Press. 



FRONTAL HEADACHE AND IODIDE OF 
POTASH. 

A heavy, dull headache, situated over 
the brow, and accompanied by languor, 
chilliness and a feeling of general discom- 
fort, with a distaste for food, which some- 
times approaches to nausea, can generally 
be completely removed by a two-grain dose 
of the potassic salt dissolved in half a wine 
glass of water, and this quietly sipped the 
whole quantity being taken in about ten 
minutes. In many cases the effect of these 
small doses has been simply wonderful. A 
person who, a quarter of an hour before, 
was feeling most miserable aud refused all 
food, wishing only for quietness, would 
now lake a good meal and resume his won- 
ted cheerfulness. The rapidity with which 
the iodide acts in these cases constitutes 
its great advantage. — Mass. Medical 
Journal. 



CONFUSION BETWEEN RODENT ULCER 
AND EPITHELIOMA. 

In the meeting of the K. K. Gesell- 
schaft der Aerzte in Vienna, November 13, 
1891 {Deutsche Mediz. Zeitung, November 
19), Adamkiewicz showed as healed a 
patient whom he had treated, apparently 
undeterred by the regrettable example set 
by Koch, by means of injections of a secret 
remedy. Four days after the injection 
healing began, and in about six weeks the 
whole surface was completely skinned over. 
As diseased foci were still to be found at 
the periphery, and as somewhat rapid skin- 
ning over of the centre of such ulcers may 
be attained by other means, the procedure 
did not meet with much commendation. 
But what was most striking was the want 
of distinction made by the speakers between 
"epithelioma" and "rodent ulcer." Both 
are epitheliomatous carcinomata, it is true; 
but the origin, microscopic appearances, 
course and prognosis of these affections are 
so entirely different, that the confusion of 
the two, or at least the want of apprecia- 
tion by the leading speakers, Billroth and 
Kaposi, of their differences, tends to bear 
out Unna's statement that no new growth 
is so misunderstood in Germany as the 
ulcus rodens. The case in point was obvi- 
ously a typical rodent ulcer of many years' 



standing attacking the neighborhood of the 
eye and spreading on to the lids. Kaposi 
had himself treated the case for years at 
intervals, whenever the patient would pre- 
sent himself, but he made no reference in 
his remarks to an ulcus rodens, and spoke 
only of hautkrebs and epitheliomata, some 
of which grew more quickly and deeply 
than others. Billroth spoke of the case 
as one of ' ' flat epithelioma, " ' ' which is also 
distinguished because it commences in 
more advanced age (im holier en alter) as 
lupus senilis, or, again, as ulcus rodens." 

Rodent ulcer is so common in England, 
and we have thus so many opportunities 
of observing it in all stages, that it seems 
to us difficult to understand why our Ger- 
man-speaking colleagues should continue 
to confuse two affections which are clini- 
cally so different as to their origin, course, 
duration, treatment and prognosis. 



POLYURIA AND SCIATICA. 

At a recent meeting of the Medical 
Society of the Paris Hospitals, Drs. Debove 
and Remond announced certain phenom- 
ena which they had observed in their 
cases of sciatica. In the first case they 
found that polyuria was present, the 
amount of urine passed daily, varying 
from % to 4.25 litres. 

Inquiry elicited the fact that the same 
thing had occurred three years before when 
the patient had suffered from an attack of 
sciatica. 

This led to further investigation and 
three other sciatic patients were found in 
whom a like condition was present. In 
one of these cases azoturia was found in 
addition to the polyuria. 

Dr. Mathieu, having heard of these 
facts from his confreres, was led to make 
investigations on his own account, aud he 
also found polyuria present in two patients 
suffering from sciatica. 

Dr. Desnos thought he had found this 
condition present in other painful affec- 
tions, as for example in hepatic colic. 



ALBUMINOUS PERIOSTITIS. 

Dr. Dzierzawski communicates to the 
Polish medical journal, the Kronika Le- 
karska, an article on the so-called "peri- 
ostitis albuminosa" of Poncet, Terrier, 
and Lannelongue. He has been able to 
find, in addition to his one case, twenty- 



July 23, 1892. 



Periscope. 



153 



seven cases reported in medical literature. 
It is an affection of the periosteum char- 
acterized by a clear, tenacious exudation, 
resembling the synovial fluid or the white 
of egg, and it is, of course, from this cir- 
cumstance that the name has been given 
it. Some authors, as Nicaise, Riedinger, 
Albert, and Duplay, look upon it as a 
special pathological form ; while others, as 
Schlange, Eoser, Vollert, Garre, and Oli- 
ver, are disposed to regard it merely as- a 
variety of purulent periostitis. Dr. Dzier- 
zawski^s own view is that it is not a disease 
sui generis, but that it is comparable to 
those cases of contagious osteo-myelitis 
where a clear fluid exudation is formed 
owing to a low type of inflammation, or to 
tubercular cases, where there are infiltra- 
tions or cold abscesses. The small num- 
ber of pus corpuscles can be explained, 
according to Schlange, by their deficient 
formation owing to the weakness of the 
inflammation, or, according to Farre, by 
supposing a secondary liquefaction of these 
bodies by a serous exudation. Under 
some conditions the periosteum may give 
rise to exudation containing mucus, con- 
sequently there is no need to suppose that 
the pus corpuscles undergo mucous degen- 
eration, and a better name for the affec- 
tion under consideration would perhaps, 
according to the author, be "non-puru- 
lent osteo-periostitis. " — Lancet. 



CROSS PARALYSIS. 

Dr. Porter showed a brain before the 
Sheffield Medico Chirurgical Society, from 
a patient who had been under his care at 
the infirmary with cross paralysis. There 
was a small tumor on the left half of the 
pons the nature of which had not then 
been investigated. The patient, a man 
aged 40, was admitted with right hemi- 
plegia and paralysis of the right side of the 
face, and internal strabismus of the left 
eye. There was never any contraction of 
the pupils. No anaesthesia and no affec- 
tion of the fifth. The knee-jerks were 
exaggerated on both sides, but especially 
so on the right, and ankle-clonus was very 
marked on the right foot. ' The speech 
was slurred and laterally the tongue in- 
clined slightly to the right on protrusion. 
There was a family history of both cancer 
and tubercle. No syphilitic history. 
The diagnosis was lesion of the pons. 
The patient died comatose seven weeks 



after admission, or four months from the 
commencement of the disease. — Lancet, 
June 20th, 1891. 



ANALGESIA AND ATROPHY OF THE 
TESTICLES IN LOCOMOTOR ATAXY. 

Bitot and Sabrazes {Rev. de Med. , No- 
vember 10, 1891) give details of 37 well- 
marked cases of locomotor ataxy, in 10 of 
which the testicles were hypo-algesic (twice 
only on one side), in 18 absolutely anal- 
gesic (once only on one side), and in 9 
healthy. The affection was more pro- 
nounced when ataxia was present, and 
even existed in the absence of any local 
loss in common sensation. Parallel with 
it there was increasing trouble in the geni- 
tal functions. There w T as no constant re- 
lation between the analgesia and the dis- 
appearance of the testicular reflex. In 5 
cases there was atrophy of the testicles 
(once, perhaps, antecedent to the nervous 
disease), the organs being soft and flabby. 
In 4 of these 5 cases syphilis was excluded. 
Among many other cases of nervous dis- 
ease, the authors only found testicular 
hypo-algesia in 3 cases, and ansesthesia in 
5; and in 5 out of these 8 cases there was 
inco- ordination of movement and absent 
knee-jerks, and 2 others were examples of 
progressive general paralysis. This affec- 
tion may also be present in chronic arsen- 
ical intoxication, and rarely in male hys- 
teria. In old people the glands are 
shrunken, but there is no hypo-algesia. In 
2 of the cases with analgesia and atrophy 
of the testicles the nerves were examined. 
The myelin did not take the stain well 
with osmic acid ; and, although presenting 
moniliform enlargements, it was not 
broken up. As to the cause of the anal- 
gesia the idea of a peripheral neuritis sug- 
gested itself; but the authors say that 
histological technique is not advanced 
enough to reveal slight lesions in the 
nerves, and that perhaps the pathogeny 
should be sought in the spinal cord. — Brit. 
Med. Jour. 



A CASE OF CONGENITAL TUBERCULOSIS. 

Sabourand publishes the following ease 
of congenital tuberculosis in Medecine 
Moderneoi 29th October, 1891:— The 
mother was a patient in St. Antoine ob- 
stetric wards. The apices of both lungs 
were dull, and signs of softening were 



154 



Periscope. 



Vol. lxvii 



heard over the left apex. The child, a 
girl, was born on the 5th of August, and 
was of normal weight and size. The 
mother made a good recovery, and was 
dismissed on the 15 August. The placenta 
had not been examined microscopically. 
When five days old the infant had a con- 
junctivitis, more serous than purulent, 
which disappeared under treatment with 
nitrate of silver. On the ninth day it 
■seemed ill, and though feeding well had a 
little diarrhoea. Next day it became 
cynanotic, and fine rales were heard over 
both lungs. No convulsions nor other 
symptom preceded death, which occurred 
on the morning of the eleventh day. The 
liver and spleen only were examined post- 
mortem. The liver was normal in size, 
weight, and color, without peri-hepatitis. 
It was riddled with tubercles varying in 
size from 1 to 2 millimetres, and equally 
distributed throughout its entire thickness. 
The spleen was small, hard, contracted, 
with the capsule thickened, and was stud- 
ded throughout with tubercles of various 
sizes, some as large as 1 centimetre in dia- 
meter. 

Microscopic examination of the liver 
shows that there is no trace of normal lo- 
bulation, the cells being agglomerated be- 
tween the tubercles. Some tubercles are 
as large as a lobule, and the centre of the 
former seems to coincide with that of the 
latter, the vein being sometimes recogni- 
zable. The histology is similar to that 
observed after experimental inoculation : 
the blood-vessels are primarily affected, 
the nuclei being most abundant round the 
arteries. The bacteriological examination 
of the liver showed multitudes of bacilli, 
chiefly intra-cellular. The stain used was 
Ehrlich's anilin gentian violet, with sa- 
frinin as a contrast stain. With the spleen, 
Ziehl's solution with nitric acid showed 
the bacilli to be present in great numbers. 

The mother died two months after the 
birth of the child. The pulmonary con- 
ditions progressed rapidly, and meningeal 
symptoms with coma set in before death. 
Post-mortem examination showed no evi- 
dence of tubercle in the breast or sexual 
organs* The lungs were permeated with 
tubercle, but there was no cavity. 

The questions as to the date of infection 
of the child and the mode of invasion are 
the most important. The post-mortem ap- 
pearances of the liver are similar to those 
seen in congenital tuberculosis of the lower 



animals, and may be accounted for by the 
fact that during intra-uterine life the blood 
is, one may say, filtered through the liver. 
The age of the child at death and the ad- 
vanced nature of the lesions show the in- 
fection to have been intra-uterine. The 
splenic condition shows the disease to have 
been a blood infection. 



MEDICINE. 

LEUCOCYTOSIS IN PNEUMONIA. 

Dr. R. von Jaksch, in the Centralbl. 
fur Klin. Med., draws attention to the 
fact that the prognosis in cases of croup- 
ous pneumonia in which leucocytosis does 
not appear is very unfavorable. He thinks 
that in these instances it would be advis- 
able to give by the mouth or hypodermi- 
cally either pilocarpine, antipyrine, or 
nuclein, all of which, according to 
Horbaczewski, increase the number of 
white blood-corpuscles. Dr. von Jaksch 
is fully convinced that pilocarpine in 
croupous pneumonia actually increases the 
number of white corpuscles when a condi- 
tion of leucocytosis already exists. For 
instance, in a patient suffering from pneu- 
monia of the right base the number of 
white corpuscles was increased 62.7 per 
cent, an hour after the hypodermic in- 
jection of 0.005 milligramme of hydro- 
chlorate of pilocarpine. This sudden in- 
crease was not due to the ingestion of food, 
as the patient during the same time was 
kept without nourishment. — Lancet. 



ELONGATION OF THE LIGAMENTUM 
PATELLAE AS A FACTOR IN THE 
PRODUCTION OF CERTAIN 
KNEE TROUBLES. 

Dr. Newton M. Shaffer concludes as 
follows on this subject : 

1 . Elongation of the ligamentum patellar 
may produce weak, painful, and apparent- 
ly inflamed knee joints. 

2. Many obscure knee-joint troubles, as 
well as impaired or difficult locomotion, 
may be explained by this condition. 

3 . Elongation of the ligamentum patellae 
may produce a disability very like that pro- 
duced by ligamentous union after trans- 
verse fracture of the patella. 

And, finally, elongation of the ligamen- 
tum patellae may be, and very frequently 
is, produced by forcibly breaking up a 
fibrous anchylosis of the knee-joint. — 
Medical Record, Jan. 16, 1892.' 



July 23, 1892. 



Periscope. 



155 



BONY DEPOSITS IN THE SKIN. 

White {Birmingham Medical Journal, 
November, 1891.) relates a remarkable 
case of this condition, and compares it 
with Mr. Hutchinson's, reported in the 
Medical Times, 1890. 

The patient was badly scalded in a rail- 
way accident in 1842, the skin of his legs 
being almost entirely destroyed. The heal- 
ing process occupied five years, the bony 
plates making their appearance at a much 
later period. Their development has been 
going on in the last twenty years, in the 
calf, in front of the knee, and at one time 
completely encircling the leg. Removal 
has been sometimes necessary on account 
of irritative dermatitis set up. 

Mr. White holds that failure of nutri- 
tion is not a sufficient, if any, explanation 
of the condition. "It results from the 
simultaneous action of the processes of 
deposition and incorporation, the least 
soluble salts of the nutritive fluid being- 
left by a particularly sluggish current to 
become subject to the selective activity of 
the connective tissue cell." 



SPONTANEOUS CURE OF DETACHED 
RETINA. 

Marchetti (Rif. Med. January 16th, 
1892) reports the following case: A man, 
aged 55, observed during November, 1890, 
that the vision of his left eye was becom- 
ing dim. This dimness increased very 
rapidly, and in four days there was left 
only perception of light. Examination 
revealed extensive detachments of the 
temporal and frontal portions of the retina, 
and of a great part of the nasal portion. 
The detachment fluctuated in the lower 
portion with the ocular movements; in the 
other parts it was distended in folds. Ten- 
sion was reduced, vitreous transparent, 
and disc normal. Vision was restricted to 
P. L., and perception of movements of the 
fingers in the temporal section of the field 
of vision only. Vision had been previously 
good, but each cornea had a central leu- 
coma, the remains of inflammation many 
years previously. He was treated with 
pilocarpin injections and iodide of potas- 
sium, and advised rest in the horizontal 
posture. In February, 1891, having con- 
tinued the treatment till then, the eye 
was in the same condition, when quite sud- 
denly, on the 16th, he regained his sight. 



This followed, apparently, on a sudden ro- 
tation of his head towards the right side, 
the patient feeling immediately, as it were, 
a blow on his useless eye. Directly after 
this he found that he could see objects dis- 
tinctly and without any difficulty, and eight 
days after he could read small type quite 
easily. In June, when he again presented 
himself for opthalmoscopic examination, 
there was a light grey streak corresponding 
to the detachment, but no displacement- 
whatever remained. The field of vision 
was nearly normal, save for colors, and the 
acuity nearly as good as before, having re- 
gard to the existence of the old leucomata. 
The author is inclined to attribute the 
sudden cure to a rupture of the detached 
portion, with escape of the subjacent fluid. 
— Brit. Med. Jour. 



SURGERY. 



ANTISEPTIC MIXTURES. 

Dr. A. Oavazzni has recently reported 
his experiments with mixtures of various 
antiseptics in the form of powders. His 
first observations were made in thirty cases 
of venereal buboes. He regards iodoform 
as one of our best remedies in these cases, 
but it has the disadvantage of not possess- 
ing marked antiseptic properties. To over- 
come this deficiency he added salicylic acid, 
which is powerfully disinfectant, but some-, 
what irritant. The irritation was, how- 
ever, avoided by the addition of subnitrate 
of bismuth which is, moreover, slightly 
antiseptic. Finally, to increase the sti- 
mulant effect of this preparation in cases 
of atonic ulcers some camphor was added. 
After numerous trials the following for- 
mula was adopted : 

Iodoform 55 parts. 

Acid Salicylic 20 " 

Bismuth Subnitr 20 ' 1 

Camphor 5 " 

The ingredients are well rubbed together 
and form a pale yellowish, somewhat mealy 
powder, which produces slight, but tran- 
sient irritation, when applied to fresh 
wounds. This mixture is an excellent 
disinfectant and stimulant in cases of 
bubo. Its disadvantage is that it encour- 
ages hemorrhage from the granulations, 
but this may be avoided by discontinuing 
it every fifth of sixth day and replacing it 
by iodol. In persons with delicate skin it 
may also produce excoriations. — Wiener 
Mediz Presse. 



156 



Periscope. 



Vol. lxvii 



ON THE RELATIVE VALUE OF PERI- 
NEAL AND SUPRAPUBIC LITHO- 
TOMY. 

Dr. Wilhelm T. Lindenbaum ( Jaroslavl, 
Russia), in the course of the last nine 
years, has made 70 perineal lithotomies in 
children under 15 years of age, with 2 
deaths; and 32 in adults, with 8 deaths. 
Besides, during 1890 he performed 10 
suprapubic lithotomies in patients aged 
from 8 to 52, with 1 death (the fatal case 
referred to, a man of 52, with pulmonary 
tuberculosis and fatty heart). The high 
operation was conducted after the follow- 
ing rule: 1. All instruments were steri- 
lized ; 2. Colpeurynter was introduced in- 
to the rectum; 3. The bladder was filled 
up with 250 Cub. Cm. of a salicylate solu- 
tion; 1. Drainage was inserted (no vesi- 
cal sutures being employed); 5. The 
patient was kept on his abdomen for from 
8 to 10 first days; 6. The dressing was 
changed once daily. The urine began to 
flow through the urethra, on an average, 
on the 20th day, the wound souncllv heal- 
ing on the 30th. As far as young child- 
ren are concerned, suturing the bladder is 
thought to be very difficult, and on the 
other hand, quite superfluous, since a 
healthy urine does not irritate the wound. 
The author's general corollaries are as fol- 
lows: 1. Perineal lithotomy in early 
childhood represents a safe operation and 
gives excellent results. A relatively enorm- 
ous percentage of deaths in old age can be 
explained by the coexistence of grave com- 
plications about viscera (especially kid- 
neys). 2. Suprapubic lithotomy does not 
offer any important advantages over the 
perineal operation. The mortality remains 
yet very high, even in children. 3. Still, 
speaking generally, in the presence of 
stones, measuring above 2 Cm. in diame- 
ter, the high section should be preferred, 
but in cases of smaller calculi perineal lith- 
otomy should be performed. — Meditzin- 
skoie Obozren'ie, No. 2, 1891, p. 133. 



"MOOSE-PAPPE" AS A SURGICAL DRESS- 
ING. 

Moose-pappe as an absorbent aseptic 
dressing, says Dr. C. G. Campbell, of 
Saddle worth, England, is not as well 
known as its merits deserve. Moose-pappe 
(sphagnum, or turf-moss) has great absor- 
bent powers, taking up twenty-one times 
its original weight, and is decidedly the 
cheapest absorbent in market. When 



placed in contact with a liquid, moose- 
pappe seizes the liquid; its bulk becomes 
rapidly and enormously increased. The 
absorbed liquid does not lie on the surface 
or between the fibres (as is the case with 
absorbent cotton and wood-wool), but is 
shut up within the capillary cells of the 
moss. Thus, though it is full of liquid, 
it does not feel wet, and, though it may 
be full of pus, it appears clean. Where 
with an ordinary absorbent, daily dress- 
ings are required, the busy practitioner 
may safely leave his moose-pappe dressing 
two or even three days untouched, and 
will find, when he removes it, not a stink 
and a gush up of sealed up pus, but a clean 
wound and no smell. 

As a dry dressing the moose-pappe of 
Dr. ^Rodolphi is, perhaps, the most con- 
venient. It can be rapidly crumbled on 
thin gauze (which is then loosely folded 
over it). Moose-pappe (Hagedorn), pre- 
pared in this way, makes a beautiful, soft, 
dry dressing for amputations or large 
wounds. As a moist compress for ulcera- 
ting surfaces, moose-pappe (Hagedorn), 
lightly dipped in a boracic or other anti- 
septic fluid, makes an ideal dressing, 
whilst, as a padding for splints, particu- 
larly in cases of compound fracture, or 
fracture complicated with flesh-wounds, 
moose-pappe will be found most satisfac- 
tory. — The Medical Chronicle, February, 
1892, p. 292 et seq. 

ANEW AURAL RETRACTOR 
Barth (Arch, of Otol., xx, 1) describes 
a new retractor for spreading the divided 
soft parts during the operation of chiseling 
into the mastoid process. It consists of 
two bars, each provided with three sharp- 
pointed hooks; these bars are connected by 
two rods and a screw in such manner that 
when approximated the hooks form a sin- 
gle line. After having divided the soft 
parts, including the periosteum, and hav- 
ing separated the latter from the bone, the 
hooks of the retractor are applied so that 
the points touch the bone at the spot where 
we wish to continue to operate. Then 
they are separated; the points of the hook 
grasp the deeper soft parts, while the arms 
from which the hooks spring separate the 
more superficial soft parts and especially 
the divided integument, and push the au- 
ricle forward. When completely separated, 
the space included between the two arms 
presents a clear field for operation. 



July 23, 1892. 



Periscope. 



157 



OBSTETRICS. 



THE BLOOD IN PUERPERAL SEPSIS. 

Ott reports from the clinic of Yon Jaksch 
in Prague (Prager medicinische Wochen- 
scJn'ift, 1892, No. 14) a case of puerperal 
sepsis in which the examination of the 
blood afforded information of interest. 
The patient was probably infected by a 
midwife who attended her; two days after 
labor she had a severe chill, followed by 
fever. The midwife who cared for her 
had a felon upon the middle finger of her 
right hand where the skin had been broken. 
During the patient's illness her urine was 
examined and found to contain albumin 
and an abundance of aceton and urobilin. 
An examination of the blood showed 
3,470,0u0 red to 15.320 white corpuscles, 
a ratio of 1 to 220. The percentage of 
haemoglobin was 8to. An examination of 
the blood stained by Gram's method showed 
the presence of numerous cocci in groups. 
Septic panophthalmitis developed on both 
sides. An examination of the colostrum 
from the breast showed the presence of 
cocci. The patient died about two weeks 
after labor, and a post-mortem revealed 
the lesions common in puerperal pyaemia. 
The cocci present in the blood, and also 
the condition of leucocytosis which was 
present, render the report of the case of 
unusual interest. — Amer. Jour. Med. So. 



PRESENTATION REPEATEDLY CHANG- 
ED BEFORE AND DURING LABOR. 

Gallois (Journ. des Sages-Femmes, April 
1st, 1892) reports the following case: — 
The patient was an imbecile, aged 24, who 
had borne a dead child four years previously. 
She was admitted into a lying-in hospital 
on August 4th. when about seven months 
pregnant. The pelvis was narrow, not 
flat. The child lay transversely in the 
pelvis, the right shoulder tending to pre- 
sent. The breech was easily brough t down 
but the foetus quickly returned to its faulty 
position. An attempt was made to keep 
the breech down with Pinard's Belt, Ga- 
lois intending to induce labor' directly the 
desired presentation was made sure; but 
the belt chafed the skin, and the feeble- 
minded patient would not tolerate syste- 
matic precautions of this kind. On 12th, 
in the morning, labor came on. A foot 
could be felt through the membranes, 
with the breech above it not engaged. In 



the evening the pains were rapid, the 
membranes intact; the patient had been 
left alone for a long time lest the waters 
should be ruptured too soon. On exami- 
nation, the face was found presenting. 
In the small hours the waters broke, the 
foetal heart sounds became weak : two hours 
later the brow presented. The child was 
delivered asphyxiated. It recovered, and 
so did the mother. The deformities found 
on the foetal head were very marked, and 
intermediate between those seen in brow 
and those observed in face presentations. 
The caput succedaneum occupied the fore- 
head but hardly reached the eyelids. The 
cheeks were spared, the lips tumefied ; there 
was right facial paralysis. — Brit. Med. 
Jour. 



HEMICHOREA IN PREGNANCY. 

Dr. Cameron in the " Montreal Medi- 
cal Journal" January, 1892, writes, that, 
as in the non-pregnant, peripheral lesions 
may cause choreic movements, which sub- 
side when the irritating part is exercised ; 
so in pregnant women peripheral irritation 
may be propagated from the uterus to the 
central organs and may keep up choreic 
movements till the cause of irritation is 
removed. This is well exemplified in the 
following case: An anaemic, neurotic pa- 
tient, subject to hysterical fits, bearing 
family rapidly., with a lacerated crevix 
and a tender retroflexed uterus, developed 
chorea of the right side of the body in the 
month of pregnancy ; in a few days the 
left side became involved while the right 
side began to improve. By appropriate 
mechanical treatment the retroflexion was 
corrected, and the chorea disappeared in 
little more than a week. 



GYNECOLOGY. 



A CASE OF PRECOCIOUS MENSTRUA- 
TION. 

Jakubovitch ( Vratch, No. 9, p. 214, 
1892 Rev. Gener. de Clin, et de Therap., 
April 20, 1892) reports the case of a girl 
who menstruated shortly after the age of 
10 years. Her period lasts for 3 or 4 days, 
and the act occurs several times in the 
course of the year. Every menstrual pe- 
riod is preceded by nervous disturbances, 
such as headache, excitement, etc. The 
external genital organs are well developed ; 



158 



Periscope. 



Vol. lxvii 



the mammary gland are of the size of an egg, 
and at the time of menstruation they swell 
up and secrete milk. Apropos of this the 
author, in reviewing the literature of the 
subject, finds the records of only 35 cases 
analogous to the present one. Precocious 
menstruation is, therefore, rare, and adds, 
that the prognosis is favorable, although 
the haemorrhages may give rise to the pro- 
duction of anaemia and chlorosis. The 
observer advises, if the loss of blood be 
considerable, the administration of hydras- 
tis canadensis and ergot. 



TREATMENT OF FIBROID TUMORS OF 
THE UTERUS BY INJECTION OF 
ERGOT. 

J. Schneck (Medical Age, April, 1892) 
gives the histories of three cases of uterine 
fibroids treated by injections of ergot into 
the substance of the tumors, with satisfac- 
tory results, and states that several other 
cases are still under observation. The 
preparation of ergot used is a good fluid 
extract, in half drachm doses, and the in- 
strument employed is the hypodermic syr- 
inge, with a long needle ; a small aspirator 
having been used in a few instances. It is 
desirable to make the injection into the 
centre of the tumor as nearly as possible. 
No evil effects have been noticed after the 
treatment. In a few instances a chill, fol- 
lowed by moderate fever, occurred, but 
these symptoms disappeared after a few 
hours. In one case reported there was an 
intramural fibroid encroaching upon the 
cervix, and about as large as an orange, 
in a patient 42 years old. Profuse menor- 
rhagia had existed for five months and 
ergot and other astringents by the mouth 
had failed to control it. Injections of 
half drachm doses of ergot into the tumor 
daily for eighteen days, and every second 
or third day afterward for the following 
month caused the bleeding to cease. 
Menstruation is regular but there is no 
inter-menstrual bleeding and the patient 
feels well, although there is no note as to 
the condition of the fibroid. 

Another patient, of about the same age 
as the first case, had profuse menorrhagia 
following a miscarriage, for the control 
of which ergot was given by the mouth, 
with no success. An examination revealed 
the presence of a large fibroid in the right 
lateral wall of the uterus. By use of an 
aspirator needle the injections of ergot 



were given once a week for nearly five 
months. The haemorrhage was controlled 
during this entire period, and at the end 
of this time the tumor was found to be 
extruded into the uterine cavity, attached 
to a thick pedicle, and was removed by the 
ecraseur. The tumor was so large that 
the wire could not surround it, and several 
portions had to be cut away first. There 
was but slight bleeding during its removal, 
probably due to the action of the ergot 
diminishing its vascularity. The sub- 
stance of the tumor was soft and friable,, 
and probably it would have broken clown 
and liquefied in a short time. The third 
case was one of fibroid tumor in the poste- 
rior wall of the womb, which had made- 
such traction upon the fundus as to cause 
inversion of that organ with procidentia.. 
The injections were practised once a week 
for two months, at the end of this time- 
the tumor began to suppurate and dis- 
charge freely. After thoroughly disinfec- 
ting the parts, the. uterus was replaced and 
kept in position by a pessary. — Un iv. Med.. 
Mag. 

CANCER OF VAGINA CAUSED BY PES- 
SARY. 

Meyer (Zeitschr.f. Geburtsh., vol. xxii, 
1891, part 1) describes the case 
of a woman who suffered from, 
primary cancer of the vagina, evidently 
caused by the irritation of a pessary which 
had been worn for a year without change 
or cleansing. The diagnosis was confirmed 
by excision of the affected part and vag- 
inal extirpation of the uterus, after which 
the diseased tissue could be examined 
under the microscope. — Brit. Med. Jour, 



PEDIATRICS. 



A REPORT OF 392 CASES OF INTUBA- 
TION, AND 139 CASES OF TRACHEO- 
TOMY DONE AT THE BOSTON 
CITY HOSPITAL. 

Prescott and Goldthwait (Boston Med- 
and Surg. Journ., 1891, cxxv., 694.) give- 
the following statistics: Three hundred 
and ninety-two cases of intubation and 
139 cases of tracheotomy have been 
reported, with a mortality-rate of 79-59- 
per cent, in the former, 88-5 per cent, in 
the latter; 2,815 cases of intubation and 
22,941 cases of tracheotomy have been 
collected and analyzed, showing compara- 
tively no difference in the mortality-rate 



July 23, 1892. 



Periscope. 



159 



of the two operations. The results depend 
more upon the nature of the epidemic 
than upon the operation. With intuba- 
tion the results depend more upon the 
skill and experience of the operator than 
with tracheotomy. 

Thirty-seven cases were seen at least a 
year and half after recovery from intuba- 
tion, with perfect voice, and with nothing 
that would indicate any ulceration from 
pressure of the tube. 

HYSTERIA IN CHILDREN, 
Jolly (Deutche med, Zeit., April 4th, 
1892) states that he has seen a consider- 
able number of cases of hysteria in chil- 
dren which might give rise to difficulty in 
diagnosis. He has frequently met with 
persistent localized pain with -convul- 
sive phenomena, and also with inability to 
use an extremity, combined sometimes 
with distinct paralysis and anaesthesia, 
especially in children who have recently 
iad acute infectious diseases. The para- 
plegic form preponderates, but occasion- 
ally monoplegia and hemiplegia may be 
observed. He has seen hemiansesthesia 
after influenza. Tremor was a common 
symptom in cases having a traumatic 
origin. He mentions also laryngeal dis- 
orders, and various affections of speech 
and hearing; in particular, stammering 
.and more or less prolonged loss of speech, 
conditions which might be cured by a 
brief application of the faradic current. 
Deafness and amblyopia might also be ob- 
served. In cases in which hysterical fits 
of laughing or crying are followed by con- 
vulsive movements of the extremities Jolly 
recommends isolation, with cold douches 
to the face, or a somewhat painful faradic 
ourrent. He relates one severe case com- 
mencing at the age of 9, in which the girl 
gradually grew worse, and indulged in foul 
and blasphemous language ; at the age of 
12 the evil spirit was exorcised by a thor- 
ough purging. In other cases with severe 
symptoms he has found the cold pack use- 
ful, or the syringing of the face with water ; 
for the latter purpose a siphon of aerated 
water may be used. — Brit. Med. Jour. 



HYGIENE. 



MILK EPIDEMIC OF TYPHOID. 
Dr. F. M. Williams, medical officer of 
health for Plymouth, has been good enough 
to give us particulars of the result of his 



inquiry into the occurence of enteric fever 
in connection with the milk supply for a 
portion of the town. Attention was first 
directed by the notification of three cases 
of enteric fever during two days in the same 
neighborhood, and the discovery that the 
households had a common milk snpply. 
The dairy which furnished the milk ob- 
tained it from a farm in the Plympton dis- 
trict, which is non-scheduled and in which 
the Compulsory Notification Act isnot ado- 
pted. This farm, which contains about 
one hundred cows, was visited, and the 
persons there employed stated that neither 
they nor their children had, during the last 
few months, suffered from illness or diar- 
rhoea. The well, the cover of which is said 
to be leaky, was within some forty feet of 
the privy cess-pit, but examination by the 
chemical analyst gave negative results. 
Two other cases were shortly afterwards 
reported from the same milk supply, and 
Dr. Williams eventually ascertained that 
there had been a death from enteric fever 
on the farm some twenty days previous to 
his visit, the deceased being a grandchild 
of the caretaker. The medical man whe 
had attended the case confirmed the cor- 
rectness of this statement, and added that 
there was another case of typhoid fever at 
that time, the patient being actually ill at 
the time of Dr. Williams' first visit. In 
conjunction with the medical officer of 
health for Plympton, steps were taken at 
once, the cows were all removed to another 
farm, the farm being closed as a dairy 
farm; the pump from the well was disman- 
tled, the well closed, and the patient re- 
moved to hospital. Seven other cases hav- 
ing the same milk supply have been notified 
within a fortnight of the first cases not in- 
cluding two that have been notified since 
closing the farm. The total number of 
cases is thus twelve. One case has termin- 
ated fatally — a young man who was ordered 
by his medical attendant to live on a milk 
diet for some ailment, and who was one of 
the earlier cases reported. 

The remainder of the cases are doing well, 
and it is hoped that there will be no more 
fatalities. It is stated that there was a se- 
vere case of enteric fever at the same farm 
some twelve months since, but no inform- 
ation as to the disposal of the excreta can 
be obtained, as the family had left the 
neighborhood. Dr. Williams is strongly 
of opinion, based on some years of experi- 
ence of health work in rural districts, that 



160 



News and Miscellany. 



Vol. lxvii 



this is the cause of the present outbreak. 
As to the means of propagating the disease 
at the farm, he points out that the man 
and his wife were both engaged in the 
dairy work milking cows, etc., and nurs- 
ing the sick child. The cesspit contained 
typhoid excreta, f and probably polluted the 
well, although chemical analysis gave no 
proof of pollution. Two families have 
suffered severely, three members in one 
family and two in another. Several other 
members of this latter family suffered for 
a few days from diarrhoea, fever, and ma- 
laise. Several hotels were supplied with 
milk from the same farm, so that there 
might have been visitors who had con- 
tracted the disease at Plymouth, and not 
developed it until their return to their 
homes or elsewhere. — Brit. Med. Jour. 



MEDICAL CHEMISTRY. 



A STABLE SOLUTION OF SODIUM SALIC- 
LATE. 

Solution of sodium salicylate for ready 
dispensing purposes very soon darkens in 
color, as every one knows, being due to 
the alkaline nature of the solution. To 
obviate this trouble, M. Rucker (Zeit. 0. 
Apoth. Ver.) recommends the addition of 
a little salicylic acid, in the proportion of, 
say, 1 to 1000 for the sodium salt used, 
so as to insure a slightly acid reaction. 
To prepare a stable 10-per cent by weight 
solution direct from the acid, it requires 
100 grams of salicylic acid, 61 grams of 
sodium bicarbonate and 1,095 grams of 
distilled water, the sodium salicylate 
formed representing approximately 122 
grams. Cold water should alone be em- 
ployed and too violent a reaction be avoid- 
ed, while the salicylic acid must be slightly 
in excess. To further insure stability, 
filter through absorbent cotton or glass 
wool. 



EXTRACTS OF ANIMAL TISSUES. 

Extracts of animal tissues for hypoder- 
mic purposes, an extension in therapy of 
Brown-Sequard's spermatic treatment, are 
prepared by d' Arson val by digesting for 24 
hours the glands or other parts of the an- 
imal (such as pancreas, spleen, brain, mus- 
cles, etc.) with three times the weight of 
glycerin, at a temperature of 28°C. To 
this is added three times the weight of 
the glycerin of recently boiled, but cooled, 



water. This extract, containing 25 per- 
cent of glycerin, is filtered and sterilized 
by exposing for one hour to carbonic acid 
gas under a pressure of 50 atmospheres, 
at a slightly raised temperature. 



NEWS AND MISCELLANY. 



SYPHILIS AMONG THE ANCIENT EGYPT- 
IANS. 

Proksch (Archives F. Dennatologie U. 
Syphilis, June 20, 1891) discusses the 
probable existence of syphilis among the 
ancient Egyptians. In studying a papy- 
rus containing instructions about the man- 
agement of a disease known to them as 
" uxedu, " he has identified syphilis. The 
papyrus gives the treatment for uxedu in 
the anus, in suppurating wounds, in the 
mouth, in the eyes, in the bones, in tu- 
mors of the head, in the body, in pustules, 
etc., thus giving an almost complete his- 
tory of the various situations in which sy- 
philis may manifest itself. The author 
concludes that the uxedu of the ancient 
Egyptians is our syphilis. 



THE OWNERSHIP OF AMPUTATED 
LIMBS 

A singular case has recently been tried 
before His Honor JudgeJones in the Bol- 
ton County-court. The plaintiff, Ellia 
Housley, sued the junior house surgeon at 
the Bolton Infirmary for £10, the value- 
of one of the arms of his son, who had been 
hurt at His work. The limb was amputa- 
ted at the infirmary, and after the opera- 
tion the patient asked for the arm, but the 
house surgeon refused to allow him to take 
it away. A day or two later the boy died, 
and the father again demanded his son's 
arm along with the body for burial. It 
was argued for the plaintiff that he had a 
right to the limb, whilst for the defendant 
that there was no cause of action. His 
Honor said the plaintiff had no property in 
his son or his son's body, and even a guar- 
dian was only a guardian during lifetime 
and not of the dead body, and there was 
no obligation to bury. After further ar- 
gument the solicitor for the plaintiff stated 
that if his Honor was against him on t^e 
common law, he could go no further, and 
there was a verdict for the defendant,, 
with costs. — Lancet. 



Vol. I,XVII, No. 5. 
Whole No. 1848. 



JULY 30, 1892 



$5.00 per Annum 
10 Cents a Copy 



A Weekly Journal. 



Established iu 1853 by S. W. BUTLER, M. D, 



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REPORTER 

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CLINICAL LECTURES. 

Prof. H. Nothnagel, Vienna, Austria. 
The Limits of the Art of Healing 161 

COMMUNICATIONS. 

G. Frank Lydston, M. D., Chicago, 111. 
Reflex Urethral and General Neuroses; Urethral 
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and Neuralgia of the Testes 169 

Dr. Freghan, Berlin, Germany. 
Clinical Contribution to the Study of Hyper- 
trophic Hepatic Cirrhosis 175 

JAmes'A. Goggans, M. D., Alexander City, Ala. 
The Diagnosis of Some Abdominal Tumoi-s Sup- 
posed to be Ovarian 179 

Franklyn J. Tower, M. D., Milwaukee. Wis. 
The ^Etiology and Bacteriology of Diphtheria. . . 181 

SOCIEY REPORTS. 

Milwaukee Medical Society .184 



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LEADING ARTICLES. 

Carbolic Acid Gangrene , 189 

BOOK REVIEWS 191 

PERISCOPE. 

Therapeutics 192 

Medicine 193 

Surgery 194 

Obstetrics..,. 195 

Gynecology 196 

Pediatrics ..... 197 

Hygiene 198 

Medical Chemistry 199 

NEWS AND MISCELLANY 199 



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THE 



MEDICAL AND SURGICAL 
REPORTER. 



No. 1848. 



PHILADELPHIA, JULY 30, 1892. 



Vol. LXVII— No. 5. 



Clinical Tiecturee* 



THE LIMITS OF THE ART OF 
HEALING.* 



By PROF. H. NOTHNAGEL, 

VIENNA, AUSTEIA. 



Honored Assemblage: — Death, disease, 
and bodily sickness of many kinds — this 
is the inheritance of suffering mankind. 
The powerful desire for life, the striving 
towards a painless existence, and the in- 
tense longing for health stand in opposi- 
tion. To the existence of these two op- 
posing facts, the art of healing owes its 
origin. 

Mankind has become submissive to the 
inevitable existence of death itself. No 
one to-day, thinks of exacting such a re- 
quirement of medicine as an immunity 
from death. To be sure, why we 
must die at all, why even in the most 
healthy subjects the mechanism of our 
organism must cease its activity after eighty 
or perhaps a hundred years of work, these 
are questions which science can only ans- 
wer very unsatisfactorily. Processes of 
material changes of any kind, either in the 
cells or organs, causing a weakening of their 
functions which are necessary for the 
maintenance of life, these are the causes. 
But the true "how" and the final "why" 
of these destroying processes still await 
explanation. 

Standing, as we do, powerless before 
death, that unchangeable law of nature, 
the desire to prolong the life of each in- 
dividual to its greatest possible limit, is 
easily understood. That disease shall not 
prematurely end life, that those distur- 

*Delivered before the Society of Natural Scient- 
ists and Physicians, at Halle, GerniaDy ; translat- 
ed from the author's MS. , as published in the 
Wiener Med. Presse. 



bances connected with or following diseases 
shall be annulled or mitigated, these are 
the requirements which are demanded of 
medicine. 

"The great and small world studies it 
through and through, only in the end to 
let the outcome be as god wills it," was 
the Mephistophelic ridicule regarding the 
real capabilities of medicine. The term 
"ignoramus" can be applied to the 
foremost scientist of to-day, as he stands 
before the most recent riddles of the human 
life — riddles, indeed, that form so large a 
component of the questions of theoretical 
medicine. But thousands of varied forms 
of misery are present with us, and in the 
hour of danger the sick call for help, and 
the suffering crave for relief from pain. 

How far, in its practical application, 
does the science of medicine fulfil the fore- 
going requirements ? 

Where are its limits, and by what are 
these limits determined? 

What is its outlook for further growth 
and usefulness? 

The fact, that the practical art of heal- 
ing has made great advances during the 
last century, and more especially during 
the latter half of the century, needs no 
elucidation. The rebuilding of pharmacol- 
ogy, the brilliant advances in ophthalmol- 
ogy, the remodelling of laryngology, and 
the astounding growth of operative sur- 
gery and gynaecology — in the field of in- 
ternal medicine, the introduction of a 
large number of efficient medicinial sub- 
stances, and of physical curative meth- 
ods, and further the recognition of the 
value of physiological, dietetic, and hy- 
gienic factors of the most varied kind — all 
these have been factors in making this a 
noteworthy epoch. Then, the immortal 
discovery of Lister, and Pasteur's discov- 
ery of the curability of the dreaded hydro- 
phobia, and not a year since the contribu- 
tions of Koch that have awakened the 



162 



Clinical Lectures. 



Vol. lxvii 



highest and most intense enthusiasm, all 
these facts give additional importance to 
the question: where are the limits of the 
art of healing? We do well indeed to al- 
ways strive towards a greater and always 
greater enlargement of these limits, and to 
hope for continued growth. It is a duty 
to strive towards such an end. But for 
the investigator, it is necessary for him to 
only see facts, and be uninfluenced by 
sentiment, and then, after quiet consider- 
ation to sum up not only the attained, but 
also the attainable. 

" To be sick, is life under altered con- 
ditions,''" is the definition of the great re- 
former in medicine, our master and leader, 
Virchow. 

What then, is healing? — To effect pathol- 
ogical changes in the organism — be these of 
a chemical or physical nature — in such a 
manner, that they are brought to a stand- 
still, the changed tissue rendered histolog- 
ically normal, and the altered functions 
rendered physiologically normal ; to restore 
the proper relations between the tissues ; 
to bring about a healthy condition of all 
the functions of the entire organic system 
— this is healing. 

In what measure is the art of healing capa- 
ble of fulfilling these requirements ? If we 
endeavor to answer this question with the 
facts at hand, we find that the short hour 
given us for this lecture will only allow 
the answer to be a very fragmentary one. 
Yet this even will be sufficient for us to 
formulate some conclusions. 

As paradigm we will let serve a condi- 
tion which belongs to the most frequent 
occurrences — interruptions of continuity 
by external violence, either accidental or 
operatively designed. These are, as every 
one knows, curable. But the limits of the 
art in this case consist in the greatest 
technical skill in the apposition of the di- 
vided surfaces, and the keeping away of any- 
thing that would be likely to act harmfully 
upon the process of healing ; but upon the 
process of healing itself — upon the organic 
reunion of the divided surfaces — all these 
precautions have no influence. The exu- 
dation of plasmatic lymph, the processes 
of growth and regeneration in the cells of 
the injured tissues — all these occur unin- 
fluenced by us. We are astonished, and 
justly astonished, at the gigantic advance 
of operative surgery since Lister's intro- 
duction of the principles of antisepsis, and 
we may well bless the name of the man who 



has rendered it possible to save the lives of 
countless sufferers, by operative treatment, 
and to restore them to health. Yet, we 
must clearly understand that this advance 
only consists in the fact that by means of 
the protection afforded by antisepsis, allow- 
able surgical procedures can be maintained 
in a condition which renders healing pos- 
sible. But the healing itself occurs by 
means of processes that are beyond our 
control. Naturally the extraordinary 
practical value of the improved operative 
methods, which our surgeons have dis- 
covered, cannot be here taken into consid- 
eration, and for the patient while this is of 
vast importance, it is not so when view- 
ing the matter from a scientific and logical 
standpoint. It must be understood that 
healing in the sense that our art controls 
by antisepsis the organic processes, is not 
affected even by the gigantic practical ad- 
vances made in consequence of its applica- 
tion. We can cure, or cause the healing, of 
an ulcer or abscess no more to-day than we 
could formerly. Excision, or opening, of 
such is not synonymous with true healing. 
As it is with the superficial interruption of 
continuity by force (operations), so it is 
with internal processes under similar con- 
ditions. In ulcerations of the stomach or 
intestines we can influence healing in so 
far as to remove the causes of danger, 
but we do not restore the lost tissue. 

In the rupture of a blood-vessel or the 
injury of cerebral substance, it is, of course, 
necessary by means of suitable methods 
to check the congestion in the brain, but 
none of our methods will remove the 
clot, or reunite the divided nerve sub- 
stance. 

Let us choose another very common pro- 
cess — inflammation. The long series of 
clinical pictures, now acute and now 
chronic, which occur in the most varied 
organs and tissues, and are all classed 
under the head of "inflammations'" be- 
cause analogous pathological processes and 
tissue changes exist in all and can heal, as 
daily experience teaches us — the acute pro- 
cesses frequently, the chronic more rarely. 
What part does therapeutics play in this 
healing ? 

In acute inflammatory processes — as our 
knowledge of to-day teaches us — there is 
no internal medicament of direct value ; only 
indirectly in special cases can such remedy 
be of value, as for example, digitalis in 
pericarditis and myocarditis ; or symptom- 



July 30, 1892. 



Clinical Lectures. 



163 



atically, as the majority of remedies in acute 
catarrhs. Our therapeutic possibilities 
consist in very ancient possessions of 
medical science, which for centuries were 
used to excess, then in part completely 
abandoned, and at the present used with 
varying frequency. Eest, cold and local 
blood-letting form the ground- work of a 
a treatment for acute inflammations, which 
under certain circumstances is helpful. 
But how frequently is such treatment 
worthless; how often not applicable! 
Think only of all the deep inflammations, 
the inflammations of the mucous mem- 
branes ; think only of all the cases where 
the process occurs with great intensity 
independent of specific forms, such as 
the tuberculous or the pneumonic. In these 
even we are far from having satisfactory 
proofs that the procedures referred to, 
even in cases where under their application 
the inflammatory symptoms subside, have 
any direct influence upon the pathological 
processes of inflammation themselves. 
True it would seem so, but the fact has 
been in no way satisfactorily eluci-. 
dated. 

As it is with the acute, so it is also with 
the chronic inflammatory processes. We 
may be able to influence recovery in cer- 
tain favorably located forms — such as 
chronic inflammatory exudation in a 
joint, inflammatory thickening of a muscle, 
or perineuritic swelling of a reachable 
nerve, by massage, gymnastics, electricity, 
hydrotherapy, various baths, and counter- 
irritation ; these are our aids. But of all 
these it can only be said that they ' ' excite 
absorption." We possess no drug that 
effects a cure by directly influencing the 
organic processes incident to such a cure. 
This must not be regarded as a mere 
"dialectic difference/' for to the patient 
it is entirely immaterial whether the 
massage or counter-irritation have acted 
directly or indirectly, so long as he is re- 
lieved from his long-standing perineuritis. 
But how is it with the application of simi- 
lar remedies in neuritis of the trigeminus 
or optic nerve? Cure, in the true sense of 
of the word, can only occur in a case of 
perineuritis when we are able to effect a 
restoration of the histological changes of 
the nerves which have taken place. The 
same must be said of chronic inflamma- 
tions of the mucous membranes, and par- 
enchyma of the organs. In the most 
favorable cases, we are in a position by 



means of baths and u cures, '' dietetic and 
general hygienic regimen, or well as cer- 
tain pharmaceutical preparations to in- 
fluence certain symptoms, as to remove 
the product of the disease ; yet the pro- 
cess of the disease in itself we do not in- 
fluence. 

But why should I tax your patience 
with the presentation of an endless list of 
unities? Why go into a description of the 
processes of degeneration and atrophies 
as they are met with in the different tissues 
and organs and give rise to the most varied 
clinical features ; why enter into a descrip- 
tion of the many diseases of the blood, 
and diseases accompanied by tissue change, 
or discuss the vast array of the various dis- 
turbances, either anatomical or functional, 
of the nervous system? Why discuss the 
thankless efforts for the cure of foreign 
growths (I do not mean excision, but 
" cure," in the sense defined above), which 
at present offers as good chances for ulti- 
mate success, as does the bottom of the 
Kamtschatka Eiver for raising the date 
palm? In every instance, so soon as we 
come to regard the matter in its true in- 
wardness, we are confronted by similar 
evidence, and arrive at the same results 
which our reasoning led us to in discuss- 
ing interruptions of continuity and in- 
flammatory processes. 

Only one group of diseases can hold our 
attention for a moment longer, since great 
interest is linked with it. I refer to the 
group of acute and chronic infectious dis- 
eases. 

Typhoid fever, scarlet fever, measles, 
and the vast list of morbid diseases of this 
group, and even sepsis can be cured. Far 
am I from denying that the art of medicine 
can aid most materially in influencing a 
favorable result in these cases, both by 
combatting the dangerous symptoms, as 
well as by means of general hygienic 
methods and dietery precautions. But is 
our art in a position to directly influence 
the process of the disease and so effect a 
cure? Our knowledge is so humiliatingly 
small that out of this enormous list of 
diseases we can only truthfully answer 
yes to this question in regard to two or 
three; these are in malaria, syphilis, and 
perhaps acute rheumatic polyarthritis, or 
perhaps even in these cases would we not 
do better by tempering our answer with 
the reservation that it at least seems to be 
a fact? It would almost seem so to me, as 



164 



Clinical Lectures. 



Vol. lxvii 



the course of malaria, even after two hun- 
dred years of the pride of practical medi- 
cine would show. Then, in acute articu- 
lar rheumatism, of its true being we know 
nothing, and while the salicylic acid treat- 
ment indeed causes a disappearance of the 
fever and articular affection, yet it has no 
influence upon the danger of subsequent 
endocarditis and its dreaded sequella, val- 
vular diseases. And so, in all other in- 
fectious diseases — so soon as they have be- 
come well developed we cannot even to-day 
produce a cure in the truly scientific ac- 
ceptation of the term. Wherever we 
may turn, we are confronted with appar- 
ently impassible barriers forming the limits 
of our art. 

Let us endeavor, from the confusing 
mass of unities, to deduct some general 
conclusions regarding the limits of healing 
and curability. 

Healing or cure is only possible so long 
as a disease is still in its course ; so soon 
as it has reached a definite end, cure is no 
longer possible. There remain changes, 
atrophies, hj^pertrophies and other sequel- 
lae of varied natures. In the commonest 
cases these changes are unaffected by ther- 
apeutics or regeneration although they 
may perchance be amenable to mechanical 
methods or the knife of the surgeon. An 
acute pleuritis is curable ; the results left 
by it in the form of pleuritic adhesions 
cannot be cured. Acute endocarditis may 
disappear, but the valvular insufficiency 
caused by it cannot be cured. Anomalies 
in change of substance which lead to the 
formation of renal gravel, may be checked 
at the outset, but the formed stone can 
only be removed by the surgeon. An ul- 
cer at the cardia of the stomach can heal, 
but the cicatrix left and causing stenosis, 
can at best only be excised. 

The possibilities of therapeutic influence 
are in many cases determined by the loca- 
tion of the disease. An aneurism if situat- 
ed at an artery of the extremities can be 
rendered harmless, but will cause fatal 
haemorrhage if located in the aorta or ar- 
teria basilaris cerebri. An abnormal de- 
velopment of fat can be checked if it is 
confined to the superficial parts of the 
body, but it will finally end in death if 
the heart muscles become involved. 

Of almost equal importance in the ques- 
tion of curability is the nature of the oc- 
currence of the disease ; whether its cause 
develops suddenly or gradually, with great 



intensity or not. The same amount of ar- 
senic that under ordinary circumstances 
would be unfailingly fatal, is well tolerated 
by the accustomed arsenic eater, cholera 
or epidemic cerebro-spinal meningitis 
may attack two similarly constituted indi- 
viduals; in the one causing death' after a 
rapid and severe course, and in the other 
ending in recovery after a comparatively 
slight illness. 

A disease becomes incurable when its 
causes continue without interruption. 

Malaria will in the end most certainly 
cause death if the infected person does 
not leave the poisonous swamp-lands that 
constitute his home. 

Bronchial catarrh remains stationary, 
and will finally end in causing a disease of 
the parenchyma, a disease of the lungs,if 
the patient remains under the influence of 
the possibly dust-laden atmosphere. 

In similar suddenness and intensity of a 
disease cause, and by similar extent of the 
local development, the individual power 
of resistance, or especial constitution of 
the subject is of great weight. The same in- 
flammation of the lungs, which a strong 
man thirty-years old, can live through, 
will end fatally in an aged subject, a 
heavy drinker, or one who has been en- 
feebled by a dissolute life or long previous 
illness. 

Finally, crimen non est artis sed aegrote. 
With this sentence a long series of cases 
must be characterized, in which every 
medical or scientific aid is unavailing, 
while theoretically of little use to us in 
answering our question yet in actual fact 
they have considerable Aveight. Under the 
most favorable conditions the most efficient 
methods fail in effecting a cure, either be- 
cause he does not or cannot conform to 
them. The most active treatment will not 
relieve the smoker of his pharyngeal catarrh 
so long as he continues to smoke. In this 
respect we are forcibly reminded of the ner- 
vousness and neurasthenia so common in our 
times. Lack of fore-sight or will-power in 
such cases prevent frequent possible cures; 
often to be sure, also, the power of external 
influences, which keep the unfortunate 
subject so long under the ban of circum- 
stances until every therapeutic endeavor 
comes too late to be of any value except as 
a passing relief, but cure can no longer be 
effected. 

Any ailment that does not fall under 
one of these categories is, in principle at 



July 30, 1892. 



Clinical Lectures. 



165 



least, curable. The actual cure of such 
is the question of the times, in our minds. 
As remarkable as such a statement may 
appear at the present condition of our 
capabilities, we see no reason why the true 
curability of malignant growths should 

always be an impossibility. 

* * * 

The following we must now acknowl- 
edge is as an undeniable fact : the actual 
healing or cure, the restoration to a nor- 
mal condition of function and tissues, 
changed either chemically or physically 
by diseases, can only be effected by living 
l^rocesses in the organism. Now, the 
answer to our question regarding the 
limits of our art, is dependent upon the 
extent to which it is, or will be, able to in- 
fluence these processes, and to determine 
whether or not it may extend the limits 
of its capabilities. And if it is shown that 
it can not do this or at best only in a very 
limited manner, then the second question 
•comes, whether its usefulness is here at 
an end, or whether other possibilities are 
not open to it, constituting a high end for 
it to strive for. 

With certainty can we say, that certain 
pathological changes stand as insurmount- 
able barriers before even the most ad- 
vanced science. Never will we be able by 
means of our art to restore lost cells or 
cause the reunion of what has been divid- 
ed, never will we be able to directly in- 
fluence the ganglia cells and train of asso- 
ciations that plays the real part in the 
manifestations of hallucinations. 

True, by means of the exhibition of 
certain substance we are able to effect 
changes in the protoplasm of certain cells 
thus giving rise to certain physiolo- 
gical effects, although how this is ac- 
complished is not understood. Many of 
the alkaloids act in this way: alcohol, 
ether, chloroform, bromine, curare, digi- 
talis, and many other drugs act directly 
upon the substance of certain , groups of 
ganglia- cells, as well as nerve and muscu- 
lar fibres ; pilocarpin, arsenic and iodine 
act upon certain glandular cells ; phosphor- 
ous upon the process of growth in the 
bones. 

When we come to analyze the cases known 
at present, however, how do we find it 
applicable to successful therapy ? Bromides 
check epileptic convulsions for a limited 
period, but they do not affect the proces- 
ses in the central nervous system. 



Alcohol in measured doses stimulates for 
a time the action of the brain and 
heart, but does not act in a curative man- 
ner in any of the pathological conditions 
which may have rendered its exhibition 
necessary. 

Morphine relieves the pain of neuralgia, 
but does not relieve the changes that cause 
the same. Digitalis relieves passingly the 
insufficiency of the cardiac muscle, tachy- 
cardia and arhythmia, but does not pre- 
vent their recurrence, neither does it 
restore to normal the fine or coarse ana- 
tomical foundations of these conditions. 

The nearest approach to true cure or 
healing which we are able to produce by 
means of drugs, is seen in the action of 
iodine upon gumma and enlarged thyroid 
gland ; but even here we must acknowledge 
that the true nature of the disease is en- 
tirely unknown to us. Even in the most 
favorable cases of unquestionable specific 
influencing of the diseased tissue in such 
a manner that the processes leading to re- 
covery must be directly ascribed to the 
remedy, still, the receding of the disease 
in the true sense of the word is effected by 
the organism itself. To be sure, if cir- 
cumstances analogous to those attending 
the action of iodine in enlargements of the 
thyroid were more frequent, the art of 
healing would be brought nearer to its 
ideal. Yet how pitiably few are these up 
to the present day! Whether or not we 
shall reach a goal by a similar train of 
thought which led our renowned Robert 
Koch to institute his experiments with 
tuberculin, clinical experience must show. 
Possibly the art of healing is destined to 
advance in this direction — at all events it 
forms a noble work of research, worthy of 
our highest endeavors. First of all, and 
even more with our advancement of 
knowledge, we must come to understand 
that the physician is only the servant of 
nature and not her master. Although, 
however, our outlook and possibilities may 
at present be very limited, yet this should 
offer no discouragement or cause us to give 
up our work without further endeavors. 
If Science cannot master Nature, it can at 
least follow faithfully, observing its 
mysteries. The warning sounded in the 
foregoing sentence gives the key to the 
secret of the success of truly great physi- 
cians. 

We must carefully investigate and con- 
firm the development, nature and results 



166 



Clinical Lectures. 



Vol. lxvii 



of morbid changes, and also under what 
conditions and by what processes the 
human organism is capable of withstand- 
ing or recovering from these disturbances, 
and when possible in a suitable manner to 
cause or assist these processes, or to imi- 
tate them, and above all to do no harm. 
This is the way in which the art of healing 
can accomplish great and good ends. His- 
tory shows most conclusively that parallel 
to the advance of our knowledge of scien- 
tific methods, our capabilities at the sick- 
bed have also advanced. Isolated excep- 
tions prove nothing against this assertion. 
The exceptions are accidents, and we can- 
not count on accidents when we are en- 
deavoring to extend the limits of our 
art. 

Allow me, by the way of illustration, to 
quote one example. A cardiac valvular 
insufficiency as such we can never cure. 
How is it then, that in spite of the neces- 
sary change of circulation, accompanying 
such an insufficiency, the patient may 
live for years in apparent health and capa- 
ble of work? The compensatory hyper- 
trophy of a certain part of the heart is the 
cause of this, and the life-retaining hyper- 
trophy itself is the physiological sequel of 
the above change of circulation. When 
this is recognized, and when we further 
have recognized that the extent of the hy- 
pertrophy corresponds in degree to the 
change of circulation which has caused it, 
and which it relieves, we may deduct the 
following, with reference to the art of heal- 
ing: First, no effort should be made to 
check the development of this hypertro- 
phy, as formerly used to be done; second, 
everything that might tend to hinder the 
development of this hypertrophy must be 
removed or kept away; third, we must 
not endeavor to excite the stronger action, 
by excitants, whatever they may be, so 
long as the condition of compensation re- 
mains. The organism has done its work, 
and our hands must not destroy or disturb 
it. 

I will refrain from any further reference 
to any special instances, by which it may 
be seen that medicine of to-day, without 
being able to directly affect the process of 
the disease, by simply following the rule 
laid down above, viz., of watching and aid- 
ing the natural processes of restoration of 
the organism itself, can accomplish more 
in this way than by any other means. We 
have been taught above all things not to 



disturb the course of natural restorative 
processes. On the contrary medicine 
should endeavor to place the organism in 
a position which will enable it to vanquish 
the pathological process, either by dietetic,, 
hygienic or climatic influences, or by a 
methodical stimulus to the material 
changes in the nervous system. The most 
careful and helpful assistance and watch- 
ing — suited to the conditions, and our 
knowledge of the processes of the disease — 
designed always to aid the natural restora- 
tive and healing processes, this forms one 
of the paths in which we may tread in 
seeking to broaden the usefulness of our 
art. 

With the knowledge that already de- 
veloped pathological processes can only be 
influenced by our art to a limited extent, 
or perhaps not at all, medicine has 
recently entered upon an entirely new 
field of labor, from which it already reaps 
a blessed and costly harvest. And in fact,, 
since in many cases we are not, and will 
not, be in a position to influence the results 
of disease in the organism, it becomes all 
the more our imperative duty to guard 
against the occurrence of the same, to 
recognize the cause of the disease and to 
render it harmless. 

This duty should, however, be accepted 
in the fullest sense ; not alone in the guard- 
ance against infectious diseases, and this 
again not alone in the enforcement of 
sanitary laws. The success of this work 
has caused us very commonly to ascribe a 
curative action to its influence, while in 
point of fact none such exists. By closely 
examining the fact, it will be seen that 
the results are obtained not by a 'pro- 
cess of cure in the scientific sense, 
but by a distinction of the cause of the- 
disease. 

When a potash solution which has been 
swallowed, has been immediately neutra- 
lized by the exhibition of vinegar or when 
the acarus scabiei has been killed by any 
local application, any one will understand 
that this is naturally only a removal of 
the harmfulness of the exciting cause of 
the disease, not a cure for the gastric lesion 
or cutaneous affection. But we must go> 
much further in this line of argument; 
the curative action of many so-called speci- 
fic remedies becomes subject to the same 
limitations. So the treatment of malaria 
with quinine must be, to all appearances, 
regarded as etiological treatment. The 



July 30, 1892. 



Clinical Lectures. 



16? 



changes in the blood-corpuscles and in 
the spleen are not cured or restored by the 
alkaloid, but the plasmodiae of malaria are 
in some way killed and the process of the 
disease in the tissues stopped. 

As the acid renders the alkali harmless, 
thus removing the cause of disease, so does 
quinine render the plasmodium in the 
blood harmless. 

The hope is by no means unjustifiable 
that in the near or perhaps more distant 
future, such a destruction of the exciting 
causes of the disease may be possible by 
means of the employment of specific reme- 
dies in other infections. After the des- 
truction of the course of the disease, the 
nature process of healing can effect a cure 
of the existing disturbances: in typhoid 
fever, the intestinal ulcers ; and the bron- 
chitis in whooping cough. It is possible 
that advance in this direction may occur 
by accidental discovery, as was the case 
with quinine in malaria and salicylic acid 
in rheumatism. All the same, the opinion 
is not without good foundation that meth- 
odical investigations in this line may also 
be fruitful of success. And although the 
battle of opinions still ivages here or there, 
and although many of the results as yet 
obtained, are only applicable to the diseases 
as found in animals, yet there is no real 
reason why the same results should not be 
reached in the disease as it appears in the 
human organism. 

The most noteworthy endeavors of the 
present, move in three directions: the 
healing of bacteriological diseases that 
already have advanced as far as clinical 
manifestations; to render harmless infec- 
tions still in the incubatious period; to 
guard against infections, or rather to pre- 
vent their occurrence. 

The last named effort has been the one 
most advanced. It can accomplish its re- 
sults by two different means. The one 
consists in the application of sanitary pre- 
cautions against infection. „ It is very 
clear that the value of these precautions, 
their establishment and maintenance, be- 
comes greater with the advance of our 
scientific knowledge. Cholera may be re- 
membered as a good example. The other 
possibility is to prevent infection by render- 
ing the individual organism immune. An 
unparalleled example of this may be seen 
in the precautionary inoculation, or vacci- 
nation, against small-pox. The result 
was reached by the simple clinical observa- 



tions of the English physician whose 
name millions have already lauded in 
gratitude. To cause immunity by artific- 
ial precautionary inoculations, forms a 
scientific fundamental principle occupying 
a formost position in the advancing 
tide of research. Whatever favorable re- 
sults it may ultimately obtain, the follow- 
ing is practical and clear: Even if we 
come to the possession of advanced methods 
in this line, we will only attempt preven- 
tive immunization in the case of such dis- 
eases of an infective nature, that affect the 
majority or at least many individuals and 
to the danger of which they seem most 
liable. So besides small-pox and possibly 
scarlet fever, would come under this cate- 
gory besides these, also whooping cough, 
pneumonia, diphtheria, typhoid fever and 
the epidemics most prevalent at the pres- 
ent time, including cholera, influenza, 
typhus, etc. Naturally geographical con- 
ditions would alter or modify this list. 
On the contrary, for many patent reasons, 
it is highly improbable that general pre- 
ventative innoculations will ever be under- 
taken in such diseases as hydrophobia, an- 
thrax, and tetanus. Such an advance 
would to-day seem rather visionary, but 
the possibility exists and we are already 
close to its fulfillment. 

The second endeavor, namely, that of 
rendering harmless an already existing in- 
fection (which, however, is still in the 
period of incubation) has an existing 
paradigm in Pasteur's inoculation in hy- 
drophobia. The number of this class of 
cases will of necessity always remain lim- 
ited. The cause for this limitation is very 
apparent. In hardly any case can this 
period of the disease (the incubation per- 
iod) be recognized at all, or can it be rec- 
ognized whether the pathogenic germs 
have entered into the human organism or 
not. How may we determine, in the case 
of a perfectly healthy man, whether there 
are tetanus bacilli or the cocci of erysipe- 
las in his system? We must have a tangi- 
ble source before we can proceed, such as 
the bite of a rabid animal. 

From a practical point of view, how- 
ever, our endeavors will be in the direction 
of that goal, in which we will be able 
to find remedies that will render harmless 
the exciting cause of disease, even after 
the same has been clinically manifested. 
In what manner these remedies act. 
whether they act harmfully upon the mi- 



168 



C lin ical Lect lives. 



Vol. lxvii 



croorganisms themselves, whether they 
render their nutritive soil in the organism 
unfavorable to their further growth, or 
finally, whether they increase the with- 
standing power of the cells (phagocytosis, 
or otherwise) — all these are secondary to the 
practical results achieved. The goal is an 
exalted one, but this is no cause for im- 
possibility of attaining it, and its attain- 
ment would be a brilliant triumph for the 
art of healing. To be sure, even after its 
achievement, it would be a mistake to im- 
agine that death from any disease in ques- 
tion could always be avoided. Even in 
such a case the severity of the disease re- 
mains a potent factor in the possibility of 
recovery, as has already been referred to in 
another part of this address. A sudden 
overloading of the organism with large 
numbers of the exciting factors of the di- 
sease, an existing lack of withstanding 
power of the organism, the institution of 
the treatment at the time when the extent 
of the tissue changes render it too late to 
be of any value, since the natural pro- 
cess of restoration cannot occur — all 
these will act as limitations to its useful- 
ness. 

Naturally the duty of the preventing 
and removing the cause of disease to the 
utmost limits, holds good in the most var- 
ied conditions, only the results of such a 
course are rarely so evident as in the treat- 
ment of bacteriological diseases. Very 
frequently the cause of the disease is en- 
tirely removed from any possible therapeu- 
tic influence. This is the case in that 
frequently referred to affection, "cold," the 
importance of which is frequently absurdly 
over-estimated, but which in some cases 
cannot be denied. In many cases the 
cause is even now entirely unknown, as in 
renal atrophy (Schrumpfniere) and leucse- 
mia, as well as many other diseases. Or 
again, the cause may be in the patient's 
manner of life, social circumstances. To 
offer single examples of all these, would 
lead us too far. 

Even the most important point I can 
here only touch upon most briefly, in the 
technical knowledge of which the power 
of the law and society itself must join 
hands in order to grasp strongly at the 
very foundation of the subject : I refer 
to the general maintenance and care of 
health. 

And although our art is unable to 
effect healing by the impossibility of 



effecting the natural processes at our will; 
and even when it finds narrow limits in 
the prevention of diseases, even granting 
that such might be the case, even then its 
field of usefulness is by no means exhausted. 
There still remains an open field of ex- 
treme value, namely, the treatment of dis- 
ease symptoms. Out of the countless 
number of i)harmaceutical preparations the 
majority are valuable in this respect, and 
apart from these the value of mineral 
springs, bath-cures, electricity and numer- 
ous other therapeutic aids. AVe must not 
under-rate the vast importauce of this part 
of the art of healing. 

For the sufferer it is frequently quite im- 
material whether this or that functional 
change has taken place in his body, as 
long as he does not experience any trouble 
from the same, his capabilities for work 
not being lessened or his life shortened. 
Not this alone, but also something vastly 
more important. It is the symptomatic 
treatment alone that often creates the 
possibility for the natural process of heal- 
ing or cure; it annuls those symptoms 
which are most dangerous to the life of the 
patient. Truly no one who has been a re- 
cipient of the successful treatment of a 
physician in oedema of the lungs or cardiac 
failure when the stamp of death has 
already been upon him, will think lightly 
of the value of symptomatic treatment. 
In this the art of healing is not only capable 
of great advancement but it is now rapidly 
making these advances in a most satisfac- 
tory manner. 

While Griesinger only thirty years ago 
complained bitterly against the helpless- 
ness of the physician to reduce high 
fevers, we now, thanks to the cold-water 
treatment, and thanks to the discovery of a 
list of most energetic antipyretics, are able 
to keep the temperature of a patient suffer- 
ing with typhoid fever, almost normal. 
Yet we no longer deceive ourselves as to 
the value of these proceedings. Antipyre- 
sis is only the relief of a symptom and 
then only questionably; the true process of 
the disease is not affected by it. Think of 
the number of hypnotics that have been 
given to us in the past four years — a wel- 
come addition to the old king of hypnotics, 
opium. Then again the number of anti- 
septics ; and pilocarpin, cocaine, diuretin, 
and many others. Equally fruitful has 
been the introduction of symptomatic 
curative methods. In this respect we need 



July 30, 1892. 



Communications. 



169 



only refer to the pneumatic apparatus 
and irrigation of the stomach. 

" In all we see life and active work. 
Budding branches and ripe fruit ! " 

And in all this how humbly must we 
acknowledge our ignorance. Every hu- 
man life that ends prematurely, every one 
whose life of usefulness is endangered by 
processes we cannot overcome ; these show 
the limits of our lot. And what is more 
poignant, the knowledge that certain 
difficulties we may never overcome, certain 
limits never overstep, and never master the 
processes of life itself. 

We would only desire to extend vastly 
the limits of our field of usefulness, and no 
matter how slowly we progress or how 
many set-backs we meet with, yet spurred 
onward with ardent enthusiasm, we look 
-always toward that guiding star, in the 
light of which we seem to read that — 

"To work in the service of mankind. 
Is the noblest duty of man. " 

PROLAPSE OF THE EXTREMITIES IN 
HEAD PRESENTATIONS. 

J. Kaeser {Centralbl. f. Gynak., No. 2 
1892), from a study of recorded cases, 
finds that prolapse of the extremities is 
far commoner in multipara? than in primi- 
parae. The complication is favoured by 
hydramnion, contracted pelvis with pre- 
vious heavy labors and twin gestation, 
since in these conditions the inferior uter- 
ine segment does not press on the head 
with firmness sufficient to prevent prolapse 
of the extremities. Prolapse of the arms 
is less serious than prolapse of the legs, 
but the cord often comes down as well in 
these cases, and. that condition is very 
grave for the child. When the membranes 
are yet entire the obstetrician must wait 
till the os is completely dilated. Then 
the protruding extremity must be pushed 
up and the head brought well down by 
external pressure. After rupture of the 
membranes, manual reposition of the 
prolapsed member must be effected ; if this 
proves unavailing and the head is movable, 
it will in many cases be advisable to turn. 
When the head is firm, reduction of the 
extremity should be cautiously attempted 
in the intervals between the pains. If 
this should fail, then according to the 
nature of the case in other respects, natu- 
ral evolution may be awaited, or the for- 
ceps or perforator may be required. — Brit. 
Med. Jour. 



Communications 



REFLEX URETHRAL AND GENITAL 
NEUROSES ; URETHRAL NEURAL- 
GIA AND HYPERESTHESIA; 
HYPERESTHESIA AND 
NEURALGIA OF THE 
TESTES. 



By G. FRANK LYDSTON, M. D.. 

CHICAGO, ILL. 



There are a few morbid conditions of a 
functional character which, although often- 
times an integral part of organic diseases 
of the organs which it is my special pro- 
vince to consider, are occasionally either 
morbid entities or else the prominent 
source of complaint on the part of the 
patient, indeed we are apt to be more 
often consulted regarding these functional 
or nervous derangements than the diseases 
upon which they frequently depend. 

There is, perhaps, no subject in the 
whole range of genito-urinary disturbances 
of greater importance than the varied 
phenomena involving nervous derange- 
ments that are due, directly or indirectly, 
to pathological conditions of the various 
portions of the urethral canal. It is cer- 
tain, also, that in no class of cases which 
come under the observation of the genito- 
urinary surgeon, is an accurate diagnosis 
of greater importance, or more difficult to 
accomplish. I feel, therefore, that a con- 
tribution to the special study and treat- 
ment of such cases is, to say the least, 
warrantable. 

HJien we consider the vast amount of 
labor and talent that liave been devoted to 
the study of the reflex neuroses of the female 
due wholly or in part to 2 )C, -t^ological en- 
tities affecting the uterus and its appen- 
dages, it is certainly surprising that more 
attention has not been given to analogous 
conditions in the male due to disturbances 
of the generative organs and especially of 
the urethra. 

Taking as our point of departure the 
prostate body, w r e will find quite a close 
similarity between some of its morbid con- 
ditions and those affecting the uterus. 
Physiologically, the prostate, or at least a 
portion of it, is the homologue of the 
uterus, there being the closest resemblance 
in the muscular structure of the two bod- 



170 



Communications. 



Vol. lxvii 



ies. If the muscular tissue becomes per- 
verted in growth, we have in the one, 
uterine myoma, and in the other, prosta- 
tic hypertrophy, the structure of the two 
morbid processes being strikingly similar. 
When, as is occasionally the case, the 
" third lobe " of the prostate becomes so 
circumscribed as to form a distinct tumor, 
it is generally not unlike a pedunculated 
fibroid. It will also be found that certain 
remedies which have a pronounced action 
upon unstriated muscular fibre, have a 
somewhat similar action upon the pros- 
tate and uterus, this being especially true 
of secale, ustilago maidis, and hammame- 
lis. Certain sedative remedies act very 
similarly upon irritative affections of the 
uterus or ovaries, and the prostate. To 
carry the argument a little further and di- 
rectly approach the subject of neuroses, it 
will be found that certain irritations af- 
fecting the prostate, will produce effects 
quite like those produced by utero- 
ovarian irritation in women. False sper- 
matorrhoea (spermatophobia) pseudo-impo- 
tency involving disgust for the sexual act, 
melancholia, hypochondria, neuralgias 
whether of the contiguous or remote ner- 
vous filaments, and nervous inhibition 
amounting to almost complete paresis, are 
all possible results of urethral or prostat- 
ic irritation, and these conditions are all 
represented by similar disturbances, such 
as hysteria and allied conditions in the fe- 
male, due to morbid conditions of the 
generative organs. The analogy between 
the results of prostatic catarrh and those 
of cervical catarrh, as shown in one of the 
cases herewith reported, is sometimes es- 
pecially striking. 

One of the interesting features of stric- 
ture of the urethra, is the ensemble of 
symptoms of a nervous character that is so 
often seen, and which neuroses are fre- 
quently entirely disproportionate to the 
degree of organic trouble present. Ceph- 
alalgia, neuralgia in various localities, par- 
ticularly sciatica, lumbar and intercostal 
neuralgia, are quite common, but are 
probably regarded by both physician and 
patient, as coincidences rather than as 
bearing any consequential relation to the 
stricture. Associated with these are 
others (quite as prominent in some cases) 
of a purely mental character, such as mel- 
ancholia, hypochondria, disturbed sleep, 
incapacity for intellectual eft'ort, and de- 
terioration of business capacity, perhaps 



associated with great irritability of tem- 
per. Disturbed digestion and general 
faulty nutrition are constant. That these- 
various morbid conditions depend upon 
the stricture is never fully appreciated 
until that organic entity is cured, when 
the complete restoration to health demon- 
strates their true relation to the primary 
source of irritation. Many of my patients 
tell me that they had become so accus- 
tomed to their little ailments that they 
had come to consider them a matter of 
course and had never dreamed of their as- 
sociation with the stricture until the lat- 
ter was cured. One of my patients re- 
marked that he did not know how sick he- 
was until he had been cured of his strict- 
ure. 

Certain cases of gleet are associated with 
considerable mental depression which is 
commonly attributed to the moral effect 
of the supposed drain upon the system. 
This mental disturbance I believe to be in 
many instances the result of reflex irrita- 
tion through the sympathetic system, 
which is so closely associated with the- 
functions and nutrition of the sexual 
organs. 

Morbid conditions of the urethra not 
only cause neurosis in other portions of 
the body, but they are often a reflex result 
of disease of contiguous structures ; thus I 
have noted cases of spasmodic stricture de- 
pendent upon hernia and varicocele. Dr. 
Otis has described some very interesting 
cases of chronic spasmodic stricture of 
reflex origin. Operations about the anus 
are very often followed by spasmodic 
stricture and urinary retention. Morbid 
conditions of the anterior portions of the- 
urethra often cause reflex disturbances of 
the deeper portion of the canal, or indeed, 
of the bladder. This is very familiar in 
connection with the results of contraction 
of the meatus. 

One of the most annoying complaints 
which the surgeon is called upon to treat 
in connection with the genito-urinary ap- 
paratus, and especially in stricture, is 
neuralgia and hyperesthesia of the urethra. 
This disorder is most often the result of 
long standing urethral inflammation, or 
stricture with its attendant gleet, and fre- 
quently persists long after organic disease- 
has apparently been cured. The majority 
of patients who suffer from urethral neu- 
rosis of this kind are either of an emo- 
tional highly sensitive nervous organiza- 



July 30, 1892. 



Communications. 



171 



tion — often simulating "hysteria" in the 
male — or of a gouty temperament with 
highly acid and concentrated urine; 
anaemic and cachectic patients are especi- 
ally liable to it if nervous or rheumatic. 
In such patients the imagination has been 
over wrought by the dread of serious re- 
sults from urethral disease, and the mind 
depressed by a sense of self-degradation. 
The condition of the mind as well as that 
of the urethra has been impaired by long- 
continued treatment of something which 
although trifling in itself perhaps, is to the 
patient, a terrible morbid entity, and a 
mental incubus from which he is never 
free except during the hours of sleep. 
Quack literature, irritating injections, 
over enthusiastic treatment, sexual starva- 
tion and excitement without gratification, 
are all disturbing elements in his case, and 
if we superadd the results of dissipation, 
intemperance and dietetic errors, what 
wonder is there that he never gets well, 
or that he magnifies the slightest unusual 
sensation about his sexual organs into 
something new, serious and startling.- 
Such patients will say to us when we try 
to convince them that their gonorrhoea, 
gleet or stricture is practically well ; " But 
doctor, I am not quite right. I have a 
funny feeling at this point in the canal," 
or the complaint will be varied by a des- 
cription of severe burning or cutting pains 
in the canal during micturition, or a tendei 
spot usually near the meatus. Sometimes 
the pain radiates to the other portions of 
the sexual organs. On examination with 
the urethroscope, nothing appears which 
would account for the trouble ; and treat- 
ment is usually of little avail, unless we 
succeed in obtaining the patient's confi- 
dence and inducing him to believe that 
his trouble is not organic and will soon 
wear away — only too often however, he 
goes from surgeon to surgeon in the vain 
endeavor to find relief, until despairing and 
disgusted he resigns himself to what he 
considers inevitable fate and lapses into 
confirmed melancholy and hypochondria. 
Great irritability of mind alternating with 
depression and melancholia. Morbid 
states of the prostatic sinus and vesical 
neck with or without co-existing, stricture 
occasionally give rise to urethral neuralgia; 
vesical calculus and tumors are especially 
liable to be complicated by it. Hyperaes- 
thesia of the urethra is so often associated 
with stricture and gleet, that it is worthy 



of consideration in every case in which ob- 
structive spasm occurs during instrumen- 
tation; some canals will be found to be so 
hyperaesthetic that a chronic spasmodic 
condition exists. In some cases of chronic 
spasmodic stricture or urethrismus, local 
lesions of the mucous membrane exist, 
while in others nothing abnormal is to be 
detected. 

Hyperaesthesia of the testicle, is an in- 
teresting condition which sometimes re- 
sults from reflex irritation from stricture ; 
more often however it is due to excessive 
sexual indulgence or the opposite extreme, 
i. e., ungratified and prolonged sexual de- 
sire. It is most apt to be associated with 
cachexias, gout, neurasthenia or anaemia. 
The testicle may be relaxed and ' soft, or 
full and firm to the feel. Oftentimes 
varicocele is present and acts as an efficient 
cause for the affection. Hypochondria, 
melancholia and various mental perver- 
sions of a delusional character are not un- 
usual, and may perhaps be associated with 
a sluggish portal circulation or dyspepsia. 
Sudden deprivation of customary sexual 
indulgence is said by Curling to be a fre- 
quent cause. 

The symptoms consist in extreme sensi- 
bility and tenderness either of the entire 
testicle or some spot upon its surface. So 
exquisitely tender is it that oftentimes the 
contact of the clothing and the various 
bodily movements cannot be borne. 

Neuralgia of the testicle, is really an ex- 
aggeration of hyperesthesia, and has in 
addition to hyper-sensitiveness, paroxysms 
of shooting cutting pain in the organ. The 
causes are much the same as for hyperaes- 
thesia-syphilis, gout, and malaria having 
a prominent place in its aetiology. Urethral 
stricture quite often and prostatic and 
bladder disorders occasionally cause it. 
The pain is much like that of renal colic 
and is sometimes attended by retraction of 
the testis from spasm of the cremaster and 
the sick, faint feeling and cold perspiration 
characteristic of shock. I believe that 
some cases are really due to irritation of 
the renal pelvis and ureter by sharp crys- 
tals in the urine, and this acting reflexly 
produces pain in the testis. Usually only 
one testis is involved. As a rule the 
patient can walk about but in the severe- 
cases he is apt to be greatly prostrated, 
and in addition he usually suffers from 
pain and soreness on movement. 

The treatment of the neuroses which 



172 



Communications. 



Vol. lxvii 



have been presented consists in following 
some very plain indication as well as put- 
ting in practice numerous general princip- 
les. First and most important of all is 
attention to the patient's mental condi- 
tion. His mind should be diverted from 
Ms physical ills, and at the same time 
kept free from all sources of sexual dis- 
quiet. Questionable literature and the 
society of loose woman must be avoided ; 
in short, an attempt should be made to 
correct the impression so prevalent among 
men, that man's chief mission upon earth 
is the procurement of material wherewith 
to cloy his sexual appetite. Once dispel 
the idea that his penis and testes constitute 
the axis around which his earthly existence 
revolves; and one will have done more for 
his patient than if lie had fed him the entire 
contents of a drug store. Having allayed 
sexual disturbances of a purely mental or 
moral character, it remains for us to secure 
for our patient physical sexual rest, it be- 
ing sometimes a matter of nice judgment 
to determine whether moderation or strict 
continence is best for the patient's well- 
fare. In a general way it may be said 
that those neuroses which are dependent 
upon or complicated by actual inflamma- 
tion, acute or chronic, demand absolute 
continence, while in those of a purely 
nervous character, moderation is to be ad- 
vised. It is always a hard matter to de- 
termine the degree of success of our pre- 
scription in this matter, as the patient's 
penis is not only quite liable to gain the mast- 
ery over his reason and judgment, but 
over his morals as well, and he will there- 
fore be apt to consider that a lie to his 
doctor, like Kip Van Winkle's drink, 
doesn't count. 

Second only to sexual rest is the correc- 
tion of urinary activity. This may be 
corrected by diet and remedies combined, 
the diet being by far the most important. 
The proper standard for a suitable diet is 
bread and milk, but this may be varied 
within narrow limits. Nitrogenized food, 
stimulants and tobacco must be strictly 
prohibited. As an adjuvant to this regi- 
men, the Turkish bath does excellent ser- 
vice. 

The best remedies to correct hyper-acid- 
ity of the urine, are the acetate and citrate 
of potassium, liquor potass, and in gouty 
or rheumatic patients (who are especially 
liable to neurotic symptoms from urinary 
disturbances) lithia, colchicum, and salicy- 



lic acid. Mineral waters are very useful, 
the Buffalo lithia and Waukesha waters 
being especially useful. Several of my 
patients claim great benefit from partaking 
freely of the Garfield Park mineral waters. 

Sedatives and anti-spasm odics are often 
useful in these cases, the following being 
of service in different cases, viz : potassium 
bromide, gelsemium, hyoscyamus, camphor 
monobromate, morphia, salixnigra and er- 
got. Tonics are often required, the best 
being the chloride of iron, strychnine, 
arsenic and quinine. In those rare cases 
of spasmodic stricture of malarial origin, 
quinine is of course a specific. Three 
very useful drugs are the phosphide and 
bromide of zinc, and the bromide of 
arsenic, these being great favorites of my 
own. 

In many cases of urethral neurosis, sur- 
gical interference is required, thus a con- 
tracted meatus must be cut, a stricture 
dilated or cut, hernia or a varicocele oper- 
ated upon or properly supported, etc. 
The paramount indication from a surgical 
standpoint, is the relief of obstructive and 
inflammatory lesions of the genito-unnary 
tract. 

Cases of irritability and hyperesthesia 
of the testes are by no means promising. 
The use of anodynes is ordinarily repre- 
hensible as the disease is chronic in char- 
acter and a narcotic habit may be readily 
acquired. If hygiene, the steel sound, 
the suspensory bandage and marriage do 
not cure, the case is apt to be hopeless. 
Galvanism and the application of ice bags 
are said to be of service. Castration is not 
to be thought of, but the idea suggests it- 
self to me that in an obstinate case, stretch- 
ing the spermatic cord with incisions into 
the tunica albuginea might be successful 
in curing the neuralgia. Hammond sug- 
gests pressure upon the cord for the relief 
of the obstinate cases, upon the theory 
that in this way the sensibility and con- 
ductivity of the affected nerve fibres will 
be obtunded. 

A very interesting case showing the 
great annoyance which may reflexly arise 
from slight irritation of the genito-urinary 
tract came under my observation a few 
days ago. • A gentleman 28 years of age 
had been troubled by frequent micturition 
especially a night for some years. At 
times he would be compelled to rise four 
or five times at night to evacuate his blad- 
der. The only point in his history of any 



July 30, 1892. 



Communications. 



173 



importance was a gonorrhoea some seven 
or eight years ago. He confessed to mas- 
turbation and sexual excess in times past, 
but stated that sexual apathy and incapa- 
city had prevailed of recent years. On 
examination I found a meatus which had 
been badly cut by some surgeon one year 
ago. Just within it was a very irritable 
and resilient stricture of a calibre of twenty 
Fr. Not a stricture perhaps, in the eyes 
of some surgeon, but -a decided stricture 
in my opinion. This contraction was so 
irritable that attempts at exploration threw 
the entire canal into a state of spasmodic 
contraction. I found it impossible to 
pass a bougie through the deep portion of 
the canal. Cocaine was applied and a meat- 
otomy at once performed. As soon as the 
meatus was free, I passed a 32 Fr. solid 
steel sound into the bladder without the 
slightest effort. The night of the opera- 
tion the patient had the first uninterrupted 
sleep that he had enjoyed for years, this 
experience being repeated every night fol- 
lowing until he left for his home in the 
west. 

We have here a case of vesical and pro- 
static hyperesthesia, and chronic spasmo- 
dic stricture — urethrismus — instantly re- 
lieved by removing the reflex sources of 
irritation, a resilient irritable meatal con- 
traction. 

Another interesting case of a somewhat 
different type is at present under my care. 
This case shows how posterior irritation 
may reflexly excite disagreeable symptoms 
in the anterior portion of the genito-urin- 
ary tract. A young man of twenty-five 
who had suffered from several severe 
attacks of gonorrhoea, presented himself 
to me complaining of severe burning and 
and hot, lancinating pains along the pen- 
dulous urethra, localized at times at a 
point one inch posterior to the meatus. 
These painful symptoms were chiefly mani- 
fest after urination although present in 
the intervals. The patient was extremely 
neurotic and suffered from sexual hypo 
chondriasis. Otherwise he was in a nor- 
mal condition. The urine presented no 
pathological features, save tripper fdden 
and mucous casts of the prostatic follicles 
of the characteristic horse- shoe nail 
variety. 

Examination with the bulbs showed a 
urethral calibre of thirty-four French, and 
an absolute freedom from contractions. 
There were several points of tenderness in 



the penile urethra, and excessive tender- 
ness in the prostatic region. Eectal exami- 
nation showed the prostate to be slightly 
enlarged. 

I made the diagnosis of urethral neural- 
gia and hyperesthesia dependent upon 
posterior urethritis and follicular prostati- 
tis. 

There was no cutting to be done, and 
the treatment therefore consisted of inter- 
mittent dilatation with large sounds, and 
the application of nitrate of silver solution 
to the prostate. These applications were 
alternated with the application of the con- 
tinuous current, positive pole, to the deep 
urethra. Internally tonics were given, 
the Tr. ferri chlor. being mainly relied 
upon. The case has slowly but markedly 
improved, a fact which is particularly 
gratifying in view of the stubborness of 
of such cases. 

I wish to state in passing that I envy 
those surgeons who have such brilliant suc- 
cess in the management of this type of 
genito-urinary neurosis as is claimed by 
some. Personally I had rather see the 
gentleman with the cloven hoof walk into 
my office, than one of these patients. 

The explanation of the obstinacy of such 
conditions is to be found chiefly in faulty 
sexual hygiene, a matter over which we- 
have but little control. 

As illustrative of the interesting charac- 
ter of some of the cases described, I take 
the liberty of presenting the following, 
selected f rom my case book : 

Case I. Reflex vesical irritability and 
intercostal neuralgia from contracted 
meatus. W. R. age 39. This gentleman 
had had numerous attacks of gonorrhoea 
in his youth, the last attack having oc- 
curred about fifteen years ago. Since this 
last attack he had been troubled with fre- 
quent micturition, necessitating his rising- 
six to eight times during the night, and 
causing great irritability of mind. Mic- 
turition was occasionally quite difficult, 
requiring fifteen or twenty minutes for its 
completion, the stream being especially 
slow in starting. Every spring and fall 
and whenever he was overworked he suff- 
ered from a severe attack of pleurodynia, 
which had been variously diagnosed as- 
pleurisy, impending pneumonia, cardiac 
neuralgia, intercostal neuralgia, etc. In 
two of these attacks in which I attended 
him, there was an elevation of temperature 
of about four degrees, with considerable 



174 



Communications. 



Vol. lxvii 



prostration, leading me to believe that the 
attacks were of a rheumatic character. On 
examination of the urethra, I found the 
meatus so small as to barely admit a small 
probe, and excessively tender and inflamed. 
A slight gleety discharge was noticeable, 
which the patient stated had been a con- 
stant symptom for years. I at once en- 
larged the meatus to 34 French, and at- 
tempted a thorough exploration of the 
-canal. I found that steel sounds would 
not pass the muscular urethra on account 
-of the intense spasm which they induced, 
soft bougies, however, passed readily up to 
18 French. Above that size could not be 
passed without producing intense pain. No 
■organic contraction of the canal could be 
demonstrated by either the urethrameter 
or bougies a bottle. The second night after 
the meatotomy, the patient slept soundly 
for the first time in some years, and he has 
continued to secure his natural rest ever 
since, it being now three month since the 
•operation. The flow of urine has become 
quite free, and starts as soon as an attempt 
at micturition is made, the act of micturi- 
tion being of normal frequency. A marked 
improvement in the general health is 
noticeable and the nervous irritability has 
in a great measure disappeared. There has 
been some increase of weight, but as the 
patient is naturally spare, this has not been 
very marked. The attacks of pleurodynia 
have not recurred, although the usual time 
for their occurrence has passed; and as 
time goes on, I am confident that the 
theory of their dependence upon the 
urethral irritation will be confirmed. The 
gleet has disappeared entirely, and there 
has been a decided increase of sexual vigor ; 
in short, as the patient expresses it, he is 
" himself again." 

Case II. General sympathetic disturbance 
and neuralgia of the testes, from stricture 
of large calibre and follicular prostatitis. 

J. 6. E. aged 45. This gentleman had 
.several attacks of gonorrhoea, the last one 
having occurred some twenty years ago. 
For the last four years he had been suffer- 
ing with irritation of the urethra, which 
had been referred to stricture, and treated 
by dilatation. Later on he had been 
"quacked " for diabetis, prostatic enlarge- 
ment, Bright's disease, rheumatism, and 
-several other afflictions, with no effect save 
to convert the patient into a confirmed 
hypochondriac. At the time he consulted 
me, he had been suffering from paroxysmal 



pain in the testes, with occasional (i burn- 
ing" sensations in the testes, perineum, 
and cranial vertex, and pains of a rheumat- 
ic character in [the limbs. On examina- 
tion of the urethra I found that it would 
admit an 18 English sound quite readily 
save some pain was experienced at a point 
one inch from the meatus. At this spot 
the bougie a bottle, demonstrated the ex- 
istence of a linear stricture of large calibre. 
The prostate was found to be somewhat 
tender, but not enlarged. On examining 
the urine I found that it contained mem- 
branous shreds, which from their appear- 
ance I judged to be from the prostatic ure- 
thra, and the result of follicular prostati- 
tis. A slight gleety discharge was noticed, 
evidently of a similar origin. 

The meatus and stricture were cut to a 
40 French, with a complete relief to the 
neuralgia of the testes. The rheumatism 
in the limbs has greatly improved, but the 
feeling of heat in the testes, perineum, 
and head has in a measure persisted, al- 
though much better. These latter symp- 
toms I attribute to prostatic irritation, 
more particularly because applications to 
the prostatic sinus, of a sedative or astrin- 
gent character, produce a marked and 
speedy amelioration of them. I have 
found also that the shreddy appearance of 
the urine was increased by each application 
to the prostate. Hot boracic acid irriga- 
tion has been substituted for these appli- 
cations, and the case is slowly improving. 
The connection between the neuralgia of 
the testes and the stricture in this case is 
demonstrated by the improvement result- 
ing from urethrotomy. 

Case III. Pseudo-impotence from con- 
tracted and irritable meatus. This case 
and Case IV I will not give in detail, but 
will present the salient points : 

A young man of 27 had suffered from 
several attacks of gonorrhoea, the last of 
which ran into a gleet which lasted about 
a year. There had been no trouble with 
urination, but about six months before I 
saw the patient, he noticed a loss of sexual 
power. He would suddenly succeed in se- 
curing an erection at times, but erection 
would suddenly cease in the act of copula- 
tion. On examination I found the penis 
and testes apparently normal, but the 
meatus was quite narrow and excessively 
sensitive. There was no deep or penile 
stricture. 

The meatus was incised to 34 French, 



July 30, 1892. 



Communications. 



175 



and sounds passed to the bladder every 
third day for several weeks. At the end 
■of a month improvement was reported, 
.and in about two months the patient re- 
ported himself as entirely recovered from 
his sexual disability. 

Case IV. Vesical atony from contract- 
ed and irritable meatus. — This patient, 40 
years of age and a gambler by profession, 
gave the usual history of numerous gon- 
orrhoeas and also of syphilis. Micturition 
had for a long time been attended by pain 
and smarting at the meatus, and a slight 
gleet had been present for some years. 
For about a year the stream had grown 
less and less forcible, until quite a stre- 
nuous effort was necessary to empty the 
bladder. On examination the meatus was 
found to be only moderately contracted, 
but very tender, the lips being everted and 
reddened. No deep strictures were dis- 
coverable. The feeble flow of urine through 
the catheter demonstrated the vesical 
atony. As the obstruction was only mo- 
derate and was congenital, the atony was 
■explicable only upon the theory of reflex 
spasm of the cut off muscle and inhibition 
of the detrusor urinse. Meatotomy to 40 
French resulted in an almost complete 
•cure as demonstrated by examination six 
months after operation. 

Other cases of a neurotic character have 
occurred in my genito-urinary practice, 
but these cases will serve for the purpose 
of illustration. In all my cases, due at- 
tention has been paid to general hygienic 
and medicinal measures, but the details of 
treatment would simply result in prolixity, 
without adding to the value of the report. 

I have found that reflex neuralgia of 
the testis, penis and cord, and chronic 
spasmodic stricture are by no means rare, 
as several instances among my patients 
serve to demonstrate. 

FATAL POISONING BY CHLORATE OF 
POTASH. 

Dr. M. J. Donahoe reports in the 
University Medical Magazine for January 
a case of a man thirty-six years old who 
took by mistake two tablespoonfuls of 
chlorate of potash in water. Four of 
five hours afterwards violent vomiting set 
in, accompanied by great pain and tender- 
ness in the epigastrium followed by album- 
inuria, and cardiac weakness, gradually in- 
creasing for a week, when the patient 
died. 



CLINICAL CONTRIBUTION TO THE 
STUDY OF HYPERTROPHIC 
HEPATIC CIRRHOSIS.* 

By DR. FREGHAN, 

BERLIX, GERMAXY. 

Laennec regarded hypertrophic cirrhosis 
as the early stage of ordinary atrophic 
cirrhosis of the liver. Todd, in 1857, was 
the first to try to show that an essential 
difference existed between the two forms. 
In 1859, Charcot and Luys contributed a 
short report to the Societe de Biologie, 
supporting the same view on purely patho- 
logical grounds. Dr. Freghan very 
frankly admits that race prejudice pre- 
vented the Germans from giving a proper 
consideration to these investigations. 
Other investigators, however, followed 
up the studies of Todd, Charcot and Luys 
and with substantial aggreement. 

Dr. Freghan reports four cases of hyper- 
trophic cirrhosis, all of which showed very 
similar symptoms and presented nearly 
identical post-mortem appearances. 

Case I. was that of a saloon-keeper aged 
51, with good family and previous personal 
history. His habits had been correct with 
the exception of moderate indulgence in 
alcoholics. The disease had developed 
gradually in the last three months, the 
patient complaining principally of in- 
creasing weakness, loss of appetite and 
indigestion. Vomiting and profuse diar- 
rhoea were recent symptoms, the bowels 
having previously been regular. For six 
weeks there had been jaundice with light 
colored stools, enlargement of the abdo- 
men and swelling of the legs, particularly 
toward evening. 

Condition on entrance: — The patient is 
a large pretty perfectly built man, mod- 
erately well nourished; icterus marked 
and general, including the conjunctivae 
and upper air-passages. Considerable 
oedema of the lower extremities, tongue 
slightly coated ; appetite not bad ; tempera- 
ture 97.6° pulse 108, respiration 24 ; urine 
scanty, dark-brown, with a yellow foam on 
shaking; much bilirubin present and a 
trace of albumin. The urine after stand- 
ing deposited a sediment of isolated epi- 
thelial cells, pus cells and hyaline casts 

* Condensed translation by A. L. Benedict, 
A. M., M. D., from the Archiv f. Path. Anat. 
v. PJvys. u, Klin Med , April, 1892. 



176 



Communications. 



Vol. lxvii 



tinted yellow. Bowels sluggish, fasces 
hard and grey and of the consistence of 
clay. Lungs normal except for moist 
rales posteriorly ; heart normal. ' 'The abdo- 
men is half -cannon, belly forward arched." 
No trace of collateral venous anastomosis ; 
no tenderness on pressure ; vague fluctu- 
ation inferiorly. Percussion verifies the 
expectation of ascites which is moderate 
and freely movable ; liver greatly enlarged 
and plainly palpable; left lobe is the most 
hyper trophied and can be traced far into 
the left hypochondrium, no irregularities 
can be felt. The margin is rounded and 
the consistence of the whole organ strik- 
ingly hard. Liver reaches from the fifth 
rib to a hand^s breadth below the arch of 
the ribs. The spleen is not palpable but 
on percussion is found to be enlarged, 
reaching from the eighth to the twelfth 
rib. 

Course of the disease. The temperature 
remained about normal, the pulse continu- 
ed rapid. The general symptoms became 
worse and worse and the patient's strength 
fell gradually but without remission. 
The icterus remained stationary. After 
eight days in the hospital the constipation 
was succeeded by watery but normally 
colored stools. The ascites increased very 
slowly but the patient complained so in- 
cessantly of the weight and distension that 
on September 11, eight weeks after ad- 
mission to the hospital^ the abdomen was 
tapped and 3000 c. c. of deep yellow fluid 
removed. Microscopical examination of 
the fluid revealed nothing. The tapping 
afforded only temporary relief. Four days 
later, the patient's intellect became dis- 
turbed and his speech was irrational and 
the articulation indistinct. For several 
days preceding, he had suffered from 
headache. A condition of sopor slowly 
deepened into coma with involuntary 
evacuations of urine and fasces and heavy 
labored breathing, and on September 21, 
death resulted. 

Autopsy. — Diagnosis : Hypertrophic 
hepatic cirrhosis, enlarged spleen, ascites, 
laryngitis, pharyngitis, catarrhal bronchi- 
tis, oedema of the lungs, hypertrophy of 
the heart, arterio-sclerosis, parenchy- 
matous nephritis. 

Skin brownish yellow, face pale, consid- 
erable oedema of the lower extremities. 
Mucous membrane of the air passages and 
pharynx icteric and covered with a muco- 
purulent secretion. Small quantities of 



clear yellow fluid in both pleural cavities. 
Left lung slightly adherent to the chest 
wall at the apex. On pressure, foamy 
fluid exudes from the bronchial tubes. 
Very little serum in the pericardium. 
Heart broadened. Tar-like fluid blood in 
the left ventricle and also strongly icteric 
chicken-fat clots. Valvular apparatus in- 
tact. Atheromatous changes above the 
aortic valves. Heart muscles yellowish 
brown, friable. The abdominal cavity 
contained about 4000 c. c. of turbid, some- 
what fibrinous, dark yellow fluid. Intes- 
tines inflated and floating on the surface 
of the fluid. Serous coat of intestines 
slightly roughened and thickened in places. 
The stomach contained dirty brown fluid, 
its mucous membrane was markedly red- 
dened in places and particularly near the- 
pylorus. Gall duct patulous and discharg- 
ing normal bile on pressure. Intestinal 
contents yellow in the jejunum, more 
brownish in the ileum. Mucous mem- 
brane of small intestines slightly reddened 
and loosened, the injection increasing to- 
ward the large intestine. Spleen enlarged 
by half, capsule greatly thickened. Sec- 
tion shows a bluish red color interspersed 
with dark blue pigment. Kidneys large- 
and thick. Capsule strips quite easily. 
Surface smooth but with a few slight de- 
pressions. Marked congestion seen on 
section. Papillae pale and abnormal. 
Cortex thickened, glomeruli moderately 
injected. Liver very large, left lobe par- 
ticularly involved. Surface uneven and 
marked by numerous granules of various 
sizes. Granules nowhere sharply limited 
but marked mostly only by slight and 
gradual depressions so that there was no 
great change of level at any place. Sur- 
face appears like shagreen with a ground 
color of pale yellow on which brownish 
zones were conspicuous. Weight of liver 
3100 grams (more than twice the normal 
weight). Texture, firm and tough. On 
section, the arrangement of acini can still 
be detected, the acini appearing as dark 
brownish red in the midst of broad streaks 
of yellowish grey connective tissue. Ven- 
ous channels patulous. Gall bladder con- 
tains about 30 c. c. of quite normal bile 
and a smooth gall stone of the size of a 
hazel-nut. Common and hepatic ducts 
and intra-hepatic biliary passages much 
dilated and everywhere patulous. Their 
mucous membrane is intact throughout. 
Case II. was that of a butcher aged 29 



July 30, 1892. 



Con i mm lications. 



177 



with good family and fair previous personal 
history except that he had quinsy in his 
youth and that he was addicted to the use 
of alcoholics. He presented about the 
same symptoms as the first patient, and, 
in addition, he had twice vomited blood 
to the amount of a pint on the same day. 
The haematemesis had not been repeated. 
As in the first case, there was a good physi- 
cal development, normal temperature, 
rapid pulse, oedema, the last more general 
than in the first patient, jaundice. The 
stools were copious, loose, of normal color. 
There was bronchial catarrh and a mitral 
direct murmur. The liver and spleen 
were enlarged as in the first case. Eleven 
days after entrance, an exploratory lapa- 
rotomy was made which verified the first 
diagnosis and revealed no opportunity for 
improving the patient's condition. There 
was some suspicion of ecchinococcus cyst, 
since the patient had had much to do with 
dogs. The course of the disease was 
steadily downward. The diarrhoea and 
the jaundice, including the coloration of 
the urine, continued. Once there was 
hsematemesis. The temperature never 
exceeded 100.40,° while the pulse remained 
constantly above 100. The last stage of 
the disease occupied four or five days, be- 
ginning with great restlessness and loud 
complaints of pain. The patient tossed 
about and writhed in the bed-clothes but 
there was no delirium. This condition 
very quickly gave place to coma from 
which the patient could scarcely be aroused 
by shouting and shaking. The pupillary 
reaction remained. 

Tubercular broncho-pneumonia was 
found post-mortem. The heart was re- 
laxed but the valves were competent in 
spite of the mitral direct murmur. Three 
thousand c. c. dark yellow fibrinous fluid 
was found in the abdominal cavity. The 
intestines presented the same thickening 
and roughening of the serous membrane. 
The gastric mucous membrane was red- 
dened and swollen, especially in the car- 
diac portion. That of the intestine was 
in places injected and covered with a 
bloody fluid. The kidneys were congested 
and the cortex somewhat icteric in streaks. 
Otherwise the kidneys were normal. The 
spleen was large and congested, its capsule 
thickened, the Malpighian bodies indistin- 
guishable. The liver weighed 3,900 
grams. Its serous covering was rough- 
ened and flecked with gray. The surface 



of the liver was uneven from projections 
of the parenchyma. The consistence of 
the liver was about as in the first case — 
tough. The gall bladder and biliary pass- 
ages were normal. 

Case III. was that of a saloon keeper 
aged 36 addicted to the use of alcohol to 
the amount of twelve or fifteen glasses of 
beer daily besides other spirits. Since 
spring he had suffered from pains in the up- 
per part of the abdomen but which never 
became intense. Except for the longer 
duration of the trouble, about eight 
months, and an early remission, the his- 
tory was not very different from the pre- 
vious two. Ascites could not be demon- 
strated. The lungs were emphysematous 
and there was much bronchial catarrh. 
The spleen was so much enlarged as to be 
palpable. There was little change till two 
days before death when delirium suddenly 
set in. After about twenty-four hours 
coma ensued and death took place soon 
after with pulmonary oedema. The post- 
. mortem diagnosis was hypertrophic hepa- 
tic cirrhosis, hyperplasia of the spleen, 
broncho-pneumonia of the lower lobe of 
the left lung, pulmonary oedema, old tu- 
berculosis of the upper lobe of the right 
lung, purulent bronchitis, gastritis, enter- 
itis. The liver weighed 4500 grams. 

Case IV. was that of a man aged 34 who 
was also addicted to drink. The urine 
contained albumin and hyaline casts 
stained yellow. The temperature and 
even the pulse were normal. The patient 
was apathetic and made little complaint. 
Four days after admission he became still 
more stupid and, soon after, comatose. 
Death came suddenly. The post-mortem 
diagnosis was made of hypertrophic he- 
patic cirrhosis, enlarged spleen, ascites, 
pulmonary atelectasis, catarrhal bronch- 
itis, pulmonary oedema, gastritis, enteritis. 
As in the third case, there was only 400 
c. c. of fluid in the abdomen. The liver 
weighed 3500 grams. The biliary passa- 
ges, as in ail the other cases, were patul- 
ous. 

A microscopic examination was made of 
the livers from the third and fourth cases, 
with almost identical results. There was 
a general and marked formation of new 
connective tissue. The whole parenchyma 
was interlaced with anastomosing lines of 
connective tissue of varying thickness. 
The new formation of connective tissue 
did not occur in the acini, but was most 



178 



Communications. 



Vol. lxvii 



marked in the lobules and was arranged in 
bands radiating between the liver-cells. 
The islands of hepatic tissue thus formed 
were irregular in size and shape and the 
rows of liver-cells were so compressed and 
distorted that the original structure was 
with difficulty recognizable. At times the 
process of formation of new connective tis- 
sue was marked by collections of white 
blood corpuscles and the connective tissue 
was composed of fine fibrils interrupted 
by only a few small nuclei. The liver- 
cells did not seem to have been destroyed 
although they appeared, almost without 
exception, flattened and atrophied in vary- 
ing degrees. There was no indication of 
fatty degeneration or a retrogressive met- 
amorphosis. The nuclei remained distinct 
and took the stain well. In the bands of 
interstitial tissue were numerous nearly- 
formed biliary- channels. They possessed a 
distinct wall lined with cubical epithelium. 
Their course was at times serpentine, at 
times nearly straight; 

Dr. Freghan proceeds to discuss the va- 
rious views taken of hypertrophic cirrhosis. 
Charcot compares it to an experimental he- 
patitis produced by ligation of the common 
bile conduit, the former resulting from 
trouble with the smaller biliary passages, 
the latter from obstruction to the main 
duct. Both of these diseases he contrasts 
as biliary forms with ordinary atrophic 
cirrhosis which is a venous form of disease. 
Attempting to follow out this theory, 
Charcot describes the newly-formed con- 
nective tissue of atrophic cirrhosis as be- 
ing located primarily about the twigs of 
the portal vein and spreading thence to 
other parts of the lobule. In hypertrophic 
cirrhosis, however, he declares that the 
interstitial formation follows the course of 
the biliary passages and is located at the 
periphery of the acini. In this way Char- 
cot explains the frequency of icterus as a 
symptom of hypertrophic cirrhosis whereas 
the typical symptoms of atrophic cirrhosis 
are those of portal obstruction. Acker- 
mann and several others have, however, 
disproved Charcot's plausible theory of the 
connective tissue. Ackermann suggests 
that the essential difference between the 
newly-formed connective tissue in the two 
kinds of cirrhosis is its retractile tendency 
in atrophic cirrhosis and the lack of such 
a tendency in hypertrophic cirrhosis. He 
considers as analagous the difference be- 
tween ordinary cicatrical connective tissue 



and that formed in elephantiasis and in 
chronic obstructive hyperemia. Accord- 
ing to Ackermann, hypertrophic cirrhosis 
is primarily an affection of connective tis- 
sue while atrophic cirrhosis consists essen- 
tially in a degeneration of parenchymatous 
cells. Ackermann and Rosenstein com- 
pare the hepatic cirrhosis to kidney le- 
sions. Rosenstein compares hypertrophic 
cirrhosis to the large kidney and partic- 
ularly to its second stage, and atrophic 
hepatic cirrhosis to the common contracted 
kidney. 

[Note. — If by " large kidney " is meant 
the large white kidney and if the ' ' second 
stage " refers to the fatty and contracted 
kidney, the analogy does not seem well 
taken since both of these are lesions of 
parenchymatous degeneration, while the 
common contracted kidney marks an inter- 
stitial change. — A. L. B.] 

To quote Dr. Freghan literally, "The 
Ackermannisch theory, yes, in many 
points doubtless overshoots the mark/' 

Dr. Freghan takes a conservative 
position with regard to the differ- 
ence between atrophic and hypertrophic 
cirrhosis, believing that the former may 
have an initial stage of increase in the size 
of the liver and the latter a final stage of 
shrinking. He lays down, however, a 
typical triad of symptoms for hypertrophic 
cirrhosis, namely, (1) enormous, usually 
gradual increase in the size of the liver, 
(2) intense icterus usually accompanied 
by colored stools; (3) ascites lacking or 
slight. Symptoms of secondary impor- 
tance are the almost constant enlargement 
of the spleen and the tendency to gastro- 
enteritis of hemorrhagic type. The dis- 
ease usually occurs between the second and 
the beginning of the third deceuniums. 
[Dr. Freghan' s'f our cases were aged respect- 
ively 29, 34, 36 and 57]. " The tempera- 
ture changes are mostly within the normal 
limits, and evening exacerbations occur 
seldom." The pulse was about 120 in 
three of the four cases. This symptom 
has not been found mentioned in other 
articles on hypertrophic cirrhosis, The 
last stage of the disease is attended by an 
increase of temperature usually with delir- 
ium, sopor and coma successively. Choloe- 
mia terminates the chain of symptoms. 
The duration of the disease is usually 
stated at three or four years but in this 
series of four cases it varied from four 
weeks to one year. 



July 30, 1892. 



Communications. 



179 



Maugelsdorf could find in the whole 
literature of atrophic cirrhosis only eight 
cases reported in which there was icterus; 
.so that this symptom alone has consider- 
able diagnostic value. The differential 
diagnosis must be made between hyper- 
trophic cirrhosis and tumors. Intra-hepa- 
tic tumors are usually carcinoma and 
multilocular hydatid cysts. The former 
has icterus and the enlargement and hard- 
ness of the liver in common with hyper- 
trophic cirrhosis, but the surface of the 
liver is usually uneven although the in- 
equalities may not be palpable. The mod- 
erate ascites and the earlier age of hyper- 
trophic cirrhosis are diagnostic points. 
The hard rounded prominences of ecchin- 
ococcus cysts, becoming soft later, the 
tenderness of the liver and its irregular 
-contour distinguish it from hypertrophic 
cirrhosis. The disease must also be dif- 
ferentiated from a second category of tu- 
mors which grow from the larger biliary 
tubes. If the closure is not complete so 
that bile passes into the intestines, the 
diagnosis is difficult. If complete, hyper- 
trophic cirrhosis may be excluded with 
considerable certainty. 

The question naturally arises, why is 
there jaundice in hypertrophic cirrhosis if 
the ducts are patulous? Charcot's theory 
that this trouble consisted essentially of a 
disease of the biliary radicles has been dis- 
proved. Rosenstein has suggested that 
there is an over-secretion of bile and a 
lessened excretion through the smaller 
tubes but this theory does not solve the 
problem. Dr. Freghan believes that Char- 
cot's theory is in part correct, that some 
of the biliary passages are involved so that 
bile is reabsorbed into the blood while 
other biliary passages are *normal and ex- 
crete bile into the intestines. 

With regard to aetiology, Dr. Freghan 
adheres to the old view that alcohol is an 
important factor. He also inclines toward 
the belief that there may be a tubercular 
clement. At any rate, hypertrophic cir- 
rhosis and pulmonary diseases — especially 
tubercular — are frequently united in the 
same patient. 

NEURALGIA OF THE TRIGEMINUS. 

Dr. Leslie (Lo Sperimentale, No. 21, 
1891) recommends snuffing a pinch of 
common salt into the nostril of the side 
affected, or throwing in a solution by 
means of a spray. 



THE DIAGNOSIS OF SOME ABDOM- 
INAL TUMORS SUPPOSED TO 
BE OVARIAN.* 



By JAMES A. GOGGANTS, M. D., 

ALEXANDER CITY, ALA. 



Our text-books often lead one to believe 
that it is quite an easy matter to differ- 
entiate between ascites and abdominal tu- 
mors, and I have recently noticed that a 
few writers have, in referring to their 
series of abdominal sections for various 
causes, stated that, ' 'no mistake in diagnosis 
was made in the whole series." 

N~ow, my experience does not lead me 
to believe that the diagnosis of abdominal 
tumors is always such an easy thing; and 
I will make a few remarks on cases which 
have occurred in my experience which will 
serve to illustrate the fact that the diagno- 
sis is often difficult, and in some cases in- 
deed, quite impossible without resorting 
to an exploratory incision. 

The specimen which I hold in my hand, 
is a part of the remains of a cystic ovary 
and tube removed from a patient, 35 years 
of age. She was taken with pains in the 
pelvis after having had her fourth child. 
This pain continued for four years before 
the abdomen began to enlarge, and at the 
time I saw her and removed the tumor the 
abdomen was extremely large. She had 
been tapped three times and large quanti- 
ties of fluid had been withdrawn. The 
canula had been left in the abdominal 
cavity for three days, and a solution of 
iodine had been injected into a cyst which 
was supposed to exist. I recognized some 
obscure form of pelvic disease and opened 
the abdomen for its removal. Two water 
buckets-full of ascitic fluid escaped from 
the abdominal cavity, when a cystic ovary 
as large as an orange was found floating in 
the pelvis. The cyst was ruptured in the 
attempt to bring it through the abdominal 
incision, the pedicle being extremely short. 
There has been no return of the dropsy, 
and the patient has made an uninterrupted 
recovery. 

The following case is one of extreme in- 
terest, being the only case which has ever 
recovered in America after operation, and 
perhaps the only one where operation was 

*Read (by title) before the Georgia State Med- 
ical Associatiou April 22, 1892, 



180 



Communications. 



Vol. lxvii 



undertaken for exactly the same condition 
in this country. 

Patient, 21 years of age, had been in bad 
health for two years, but her abdominal 
pains had existed only about eight or ten 
months. The abdominal enlargement was 
first noticed only three months before I 
first saw her. Her father and brother, 
both physicians, had made the diagnosis 
of abdominal dropsy, and upon my first 
examination I thought that I had to deal 
with an ovarian cyst. Upon further in- 
vestigation I recognized some obscure form 
of abdominal cyst which could be el- 
ucidated only by an exploratory incision. 
This was made and the cyst proved to be 
one of the mesentery. The removal of 
the sac was impossible, consequently it 
was incised and emptied of a large amount 
of thin fluid, the incised lips drawn into 
the abdominal incision, and a glass drain- 
age tube introduced to the bottom of the 
cyst and drainage kept up. until recovery 
was complete. 

The second specimen I show you is a 
multilocular cyst of the ovary. It was re- 
moved from a patient, 45 years of age. 
The abdomen was quite full of ascitic fluid, 
and fluctuation in the cyst was very indis- 
tinct. In fact the fluid in the cyst was 
only semi-fluid. The diagnosis in this 
case was almost impossible. From the 
fixity of the tumor it seemed to be a most 
unfavorable case on which to operate ; but 
there was much distress, and as the uterine 
cavity was not elongated, and there were 
no other signs indicative of malignant dis- 
ease, I consented to operate, with the re- 
sults as I show you. The patient made a 
perfect recovery. 

A few weeks ago I was asked to see a 
lady who had been told that she was preg- 
nant, and the symptoms pointed very 
clearly toward pregnancy, the menses hav- 
ing ceased to flow quite suddenly. It 
turned out to be a dermoid cyst which in all 
probability may have been solid originally, 
and very closely connected with the uterus. 
I must think that all abdominal surgeons 
who have much experience encounter more 
or less difficulty in the diagnosis of many 
cases. And I believe that we should ex- 
haust every means at our disposal to make 
a perfect diagnosis, but after doing all this, 
there are still cases where there is manifest 
serious abdominal disease, and our course 
is quite clear that we should not wait for 
a post-mortem examination to clear the 



way, but should boldly make an explora- 
tory incision and give the patient a chance 
for life. I can recall cases sufficient to es- 
tablish in my mind the fact, that many 
lives may thus be saved, which would, 
without exploratory incisions, have been 
sacrificed. I make it a rule to regard all 
female patients, who are invalids and suf- 
fer from incapacitating pains, with surgi- 
cal suspicion, whether they have a tumor 
or not. If I can not make the diagnosis 
perfectly clear, it in no way interferes 
with me, for I believe the way to duty is 
quite clear, and that the condition is an 
unnatural one and demands an operation. 
I am not an advocate for abdominal sec- 
tion for mere symptoms, especially dysme- 
norrhea and the neuroses, but am firmly 
of the opinion that we should always be 
able to put our hands on something that 
we know is pathological, and is causing 
serious symptoms, before we subject the 
patient to such a grave procedure. The 
point I wish to bring out in this paper is> 
that it is altogether unnecessary to wait 
and try to map out all of the pathological 
conditions that may be present in a given 
case before an operation is undertaken. 



RESECTION OF THE INFERIOR MAX- 
ILLARY NERYE. 

Dr. v. Vamossy reports a case treated 
by ZuckerkandFs method and describes 
the operation as follows: "The incision 
is mada on a line drawn from the tragus to 
the middle of the naso -labial fold, so that 
one-third of its length is over the masseter 
and two-thirds in the cheek. Cautiously 
dissecting down to the fascia of the mas- 
seter, Steno's duct and the facial nerve are- 
to be drawn aside. After the moderate 
haemorrhage has* ceased, the fascia is open- 
ed and the fat removed with forceps and 
scissors. There is now a cavity, whose 
bottom is the buccinator, and which is 
bounded behind by the internal pterygoid 
and without by the masseter muscle, the 
ascending ramus of the jaw and the tendon 
of the temporal muscle. At the posterior 
part of the latter the nerve is found. It 
is easiest found by tracing back the branch 
which is found at the bottom of the wound 
upon the buccinator muscle. From 2 to 
cm. of the nerve should be excised. 
V. reports a successful case. The only 
drawback of the operation is its bad cos- 
metic result.'* — Wien. Med. Presse, No. 
48, 1891. 



July 30, 1892. 



Communications. 



' 181 



THE .ETIOLOGY AND BACTERI- 
OLOGY OF DIPHTHERIA.* 



By FBANKLYN J. TOWER, M. D. 

MILWAUKEE, WIS. 



Although this is a subject which is 
causing a great deal of discussion in the 
medical world and so much is at present 
written on it, I have no apology to offer 
for reading this paper before the Milwau- 
kee Medical Society. The particular point 
I wish to elucidate and emphasize most 
strenuously is the examination of all mem- 
branes or other exudates in cases of sus- 
pected diphtheria and to show the ease 
with which it can be done by any physi- 
cian possessing a microscope of four or 
five hundred diameters magnification and 
a few modest accessories which should be 
in the appanage of all practitioners of 
medicine. 

There is probably among the diseases 
which we are called upon to treat, . none 
more difficult to diagnose than diphtheria ; 
and when we fail to recognize it, in no in- 
stance are the consequences likely to be 
more disastrous to others exposed. On 
the other hand, when every case of throat 
difficulty is called diphtheria and treated 
accordingly, there is an unnecessary isola- 
tion, an unnecessary expense both to the 
government and patient and with but one 
possible advantage; praise for the doctor 
upon the rescue of his patient from the 
grave. On this so-called advantage I 
think you will agree with me when I in- 
form you that in 880 cases which have 
come under my indirect notice I find that 
50 per cent, recover within 48 hours : and 
if this is diphtheria it is a disease of most 
benign type and instead of dreading to 
care for cases we should delight in a dis- 
ease with such a termination. 

Several have put forth the assumption 
that filth was the direct cause of diphth- 
eria but all such theories have long since 
been exploded. 

In 1868, Oertel discovered in the diph- 
theritic exudate a micrococcus ; Cohn also 
found them and called them micrococcus- 
diphtheriticus ; but Billroth, Klebs and 
others showed them to be the pyogenic 
bacteria which without doubt we find in a 
large per cent, of all throat affections and 

*Read before the Milwaukee Medical Society, 
May 24, 1892. 



which if in sufficiently large numbers will 
produce grave and general toxaemia, but 
such conditions are not contagious and in 
no case does paralysis follow, and we have 
usually a rapid convalescence. The pseudo- 
diphtheria described in which a claim is 
made that a non-toxic bacillus identical with 
the Klebs-Loeffler bacillus (to be later de- 
scribed) is found, is probably a pyogenic mi- 
crococcic disease with occasional bacilli, 
for I have failed to corroborate the asser- 
tion and believe that there is but one 
diphtheritic germ and as Roux and Yersin 
hold that the other bacillus found by some 
investigators is but an attenuated form of 
the Klebs-Loeffler bacillus, there being but 
one thing which may argue against this, 
i. e., the Klebs-Loeffler bacillus changes 
the alkaline reaction of the culture media 
to acid while the spurious bacillus does 
not. 

In 1883 Kelbs isolated a peculiar bacil- 
lus always present in diphtheria, conducted 
many experiments upon it which were 
verified by Loeffler in 1884 and later by 
Brieger and Frankel, Roux and Yersin, 
Simonds, Klein, Welsh and Abbot and 
many others. 

Osier states in his late and very excel- 
lent work on practice that the poison of 
diphtheria is not given off by the breath ; 
but owing to many instances of infection 
through the air only, with which I am cog- 
nizant, I cannot agree with him for I 
have also been enabled to infect tubes of 
media with the breath from a diphtheritic 
blown through a glass tube bent many 
times, so that fluid particles could not 
reach the culture media. 

To Wagner, Weigert and Oertel are we 
indebted for the descriptions of the min- 
ute changes which take place in diphthe- 
ria, the always perfect technology of 
Weigert showing itself in every case. 

Klein, of London, in 22 cases of diph- 
theria found the Klebs-Loeffler bacillus 
in all and in those examined in which 
they were not found the cases were not 
contagious and recovered rapidly. 

V. Bates found with no exception the 
bacilli in all cases examined. 

In the series of 342 cases compiled by 
Johnston, of Montreal, examined by six- 
teen different men, 307 cases were found 
in which the bacilli were present, 35 cases 
absent, 24 of these were of Dr. Prudden's 
cases ; and it is well here to notice that 
these were all cases of sore throat of chil- 



182 



Communications. 



Vol. lxvii 



dren, all inmates of an institution in 
which there was an epidemic scarlatina 
and erysipelas, so that these should go for 
naught. The other eleven cases were in- 
stances of one or two failures in a large 
series, as in 52 cases examined by Beck, 
in two of which he failed to discover the 
bacillus. 

Buffer in the British Medical Journal 
in a preliminary paper on this subject 
gives many interesting notes on examina- 
tion, and also some good staining pro- 
cesses. Simonds in an elaborate article 
remarks that every false membrane which 
does not contain the Klebs-Loeffler bacillus 
is not a diphtheritic product, and writes 
very exhaustively on the morphology of 
the organism. In the exjDeriments on 
animals, of Eoux and Yersin, the import- 
ant fact is disclosed that the bacillus can 
be found as early as six to fourteen hours 
after the inoculation, and it is well known 
that in a 24 hours culture, the bacilli will 
have developed so that they can be seen 
in colonies and on steamed potato show 
the characteristic thin, colorless, glassy 
scale. It might be well at this point to 
call your attention to the description of 
the bacilli under consideration ; they are 
about the length of the tubercle bacillus 
and twice as thick, that is, about 3 ; a in 
length by 6,a in thickness ; they exhibit a 
variety of bizarre and various forms; are 
often thickened upon one or both ends ; in 
which latter case the central tenuity may 
be nearly invisible, giving the appearance 
of a diplo-coccus, and may be sometimes 
bent like a comma baccillus. They are 
stained in two minutes in solutions of the 
methyl blues, or in 15 minutes by Gram's 
method; they grow well on gelatine bouil- 
lon, blood serum, steamed potato, or in 
sterilized milk, are killed by an exposure 
to 58° temperature for ten minutes, do 
not grow, except sluggishly, at a tempe- 
rature below 18° ; they form no discovera- 
ble spores, but are extremly tenacious of 
life, as they may be dried for years and 
then recover and show their vitality upon 
implantation in a proper soil ; they form 
an exceedingly active toxalbumin. 

In 1890 in one of the numbers of the Ber- 
liner KlinischeWochenschr 'if % Brieger and 
Frankel give an exhaustive article on 
ptomaines or bacterial poisons, as they 
designate them, and give many experi- 
ments of the filtered cultures of the Loeffler 
bacillus. According to their researches, 



the ptomine is rendered innocuous by ex- 
posure to a temperature of 100° for twenty 
minutes, or two hours at 58° ; when in- 
jected into animals, caused multiple cell 
necrosis and paralysis, but no membrane: 
the actual presence of the bacilli them- 
selves being necessary for the formation 
of the exudate ; the paralysis even occurr- 
ing after many weeks. 

In 1887 Loeffler made the first experi- 
ments on this ptomaine by making ether 
extractions of bouillon cultures and evap- 
orating to dryness, dissolving the resi- 
duum in water and making from the re- 
sultant solution the inoculations. 

According to Eoux and Yersin the 
ptomaine introduced into the stomach 
causes little trouble; alcohol precipitates it 
from solution; carbolic acid has also the 
same property and a small amount added 
to cultures diminishes their toxicity. 

The bacilli are found only in the most 
external portions of the membrane so that 
on section and proper staining the bacilli 
can be seen confined only in that part of 
the membrane. 

This exudate consists of an aggregation 
of dead cells most of which have become 
hyalin material ; and the nuclei when seen 
have suffered a fragmentary destruction. 
The first change which takes place when 
the bacilli have fallen on a proper soil is a 
cell necrosis caused by the ptomaine, par- 
ticularly of the epithelium and leucocytes 
which become paralyzed and are unable to 
perform their function of phagocytosis. 
The irritation causes an exudation of fibrin 
elements agglutinizing the whole together 
and the pseudo-membrane has now a layer : 
and it is thus that there are many layers 
formed which can be seen by placing a 
diphtheritic exudate in water when the 
layers will separate. Following the cell 
death a hyalin transformation or coagula- 
tion necrosis occurs. 

At a late meeting of the Berlin Medical 
Society a lengthy discussion was called out 
by a paper read by Baginsky on the etiolo- 
gical relationship of the Klebs-Loeffler 
bacillus to diphtheria in which the impor- 
tant and general decision was reached that 
an absolute diagnosis of diphtheria could 
not be made without a bacterological ex- 
amination. In 154 cases of so-called diph- 
theria, Baginsky found the Klebs-Loeffler 
bacillus in 118, the mortality of which was 
40 per cent; only 25 per cent, ran a mild 
or favorable course: of the 36 cases in 



July 30, 1892. 



Communications. 



183 



which only cocci were found, only four 
proved fatal or 11 per cent. ; and one of 
these was complicated with measels and 
died from pneumonia; two developed bilat- 
eral empyema and the other was admitted 
with a severe paralysis, in which latter case 
the bacilli had probably given way to the 
coccic invasion and it was a true case of 
diphtheria; which would give but a mor- 
tality of 8 percent, in the coccial variety, 
if I may be allowed the term; and they all 
developed sufficient complication to prove 
fatal. 

I have six cases which I desire to refer 
to, all of which have come under my notice 
in practice. Case one: female, age 18 — 
all the symptoms of diphtheria; exudate 
covered both tonsils extending back over 
the entire pharynx, no bacilli found, and 
on this result called it a tonsilitis — other 
children were exposed who had not had 
diphtheria — case recovered in three days 
and the other children remained well. 

Case two: Female, age 7, small patches 
on right tonsil and uvula, very light case, 
bacilli present, child isolated but brother 
came down in a few days. 

Case three: Male, age 11, brother to 
case No. 2, membrane very extensive, 
great prostration, bacilli found, faucial 
paralysis developed and remained for a 
long time. 

Case four: Female, age 10, contagion 
from sister who died three days previous 
to my being called, membrane extensive, 
nasal and laryngeal variety and extended 
as far down as I could see, bacilli very 
numerous. 

Case five: Male, age 6, disease infecting 
the nose principally, uvula slightly 
affected, many bacilli present, exposed to 
child of neighbor who died. 

Case six: Female, age nine, membrane 
extensive, bacilli present both in exudates 
and in a piece of expectorated membrane, 
nasal voice and difficulty in swallowing re- 
mained for some time. 

I have examined all cases of throat di- 
sease that have come under my notice and 
when the bacilli were found I had many 
reasons also for believing my case to be 
diphtheria, and when not present I have 
never seen contagion follow, any paralysis, 
or even slow convalescence. My method 
is as follows in these cases — I carry a few 
cover glasses on my second visit, take two 
or more, clean them, rub a little of the 
tonsilar, faucial or nasal exudate on them 



or put a particle of the membrane between 
two and press it out flat-slide the glasses 
apart and dry for 2 or 3 minutes in the 
atmosphere, put covered glasses together 
and return wrapped in paper to my pocket 
until my return home- when in a few 
minute I find, or not, the bacilli: often 
times there are micrococci of many kinds 
and spirilla ; even the leptothrix found in 
the mouth is often seen, but no trouble 
will be had in seeing and determining the 
proper bacilli. When the disease has 
progressed and the Kelbs-Loeffier bacilli 
are present in considerable numbers they 
are nearly if not quiet alone. In all cases 
of suspicious throat difficulties it is well 
to examine with a view to the determina- 
tion of the presence of the bacilli. In 
Case I. which I recited, as in many others 
which I have seen, I was inclined to call it 
diphtheria on my first visit, but did not 
solely because I failed to find the bacilli, 
and though others were exposed to the 
case no contagion followed. 

I must of necessity arrive at the con- 
clusion that a microscopical examination 
of membrane or exudates is of much value 
in the diagnosis of this disease. 

A few words on some of the late ex- 
periments with the chemistry of the tox- 
albumins of diphtheria or albumoses as 
they are now called, will no doubt hold 
attention. Injections in animals of minute 
doses produce a Wallerian degeneration of 
certain nerves, seeming to be greater in 
motor nerves and to affect particularly the 
terminals; alternate fibrils are attacked, 
accounting for the recovery from diphthe- 
ritic paralysis, we have therefore in this 
substance not only a fever producer but a 
true nerve poison. 

By making extracts of the tissues of a 
corpse dead of diphtheria, doing so within 
a few hours after death to preclude the 
entrance of saprophytic bacteria, not only 
can a toxalbumin be removed, but also an 
organic acid which has far less virulency 
when inoculated into animals. These 
albumoses are precipitated though not 
coagulated by alcohol, are soluble in 
water and not precipitated therefrom by 
ebullition. 

According to Roux and Yersin, .000-4 
gm. is capable of killing 8 guinea pigs of 
400 gms. weight each, or two rabbits of 3 
kilo-grams each. 

Martin concludes that the effect of this 
poison in the body is a digestive process ; 



184 



Society Reports. 



Vol. lxvii 



the proteids of the body upon digestion 
forming these albumoses and organic acid. 
In anthrax we have an alkaloidal poison ; 
in diphtheria it is probably a ferment. 
(For discussion, see Society Reports.) 
110 Mason St. 



SOME POINTS CONCERNING THE OPEN- 
ING OF THE MASTOID PROCESS. 

Heiman (Arch. ofOtol., xx. 2) sums up 
the indications for the operation as follows : 
1. In acute purulent otitis media, com- 
plicated with inflammation of the mastoid 
process, when the inflammatoy symptoms 
do not yield to antiphlogistic treatment and 
Wild's incision. 2. In acute and chronic 
purulent otitis media, when the escape of 
the secretion is impeded by granulations 
in the middle ear or stenosis of the exter- 
nal auditory canal, or when there is a sus- 
picion of inflammation of the mastoid pro- 
cess. 3. When the mastoid process is ap- 
parently healthy, but the removal of pus 
or cholesteatomatous masses through natu- 
ral channels is impossible, and symptoms 
dangerous to life manifest themselves. 4. 
In congestive abscesses and fistulas in the 
region of the mastoid process. 2. In per- 
sistent, continuous pain in the mastoid pro- 
cess, yielding to no other treatment, es- 
pecially when it seems sensitive to pres- 
sure. 6. As a prophylactic operation, in 
symptoms of retention of secretion and in- 
flammation of the mastoid process when 
death is to be feared on account of imper- 
fect disinfection. 7. In acute purulent 
otitis media, in which there is no inflamma- 
tion of the mastoid process, and no reten- 
tion of secretion, but in which the dis- 
charge is very profuse, does not yield to the 
usual methods of treatment after a certain 
time, or even increases. 8. When there 
are distinct symptoms of inflammation of 
the brain and the meninges. 

Heiman has used the trephine d cre- 
mailliere of Pasteur for opening the mas- 
toid, and has received the following im- 
pressions from its use: 1. The removal of 
the compact portion of the mastoid process 
is much more rapid than with the mallet 
and chisel. 2, The edges of the wound 
need not be rendered smooth after the op- 
eration. 3. The different size of the tre- 
phines permits the formation of a wound 
in the bone of the desired size. 4. Shock 
is entirely obviated. 5. The depth of the 
wound can be graduated with exactness. 



Society IReporte, 

MILWAUKEE MEDICAL SOCIETY. 



Stated Meeting, May 2£th, 1892. 



Dr. F. J. Tower read a paper on the 
^Etioloay and Bacteriology of Diphtheria. 
(See page 181.) 

DISCUSSION. 

Dr. Miles H. Clark: I have very 
little to say in opening this discussion, ex- 
cept words of commendation for the paper 
of Dr. Tower. I do not think that there 
can be any doubt in the minds of any of 
us as to the advisability of microscopical 
examination in order to determine a doubt- 
ful case. As far as I myself am concerned, 
I have been singularly fortunate, in hav- 
ing but one case of diphtheria since I have 
been in the city, but I have had any num- 
ber of cases of tonsilitis and cases doubt- 
ful enough in my own mind so that I 
have been rather suspicious and at certain 
times anxious, for fear that contagion to 
other members of the family might follow ; 
and it seems to me that with this method 
before us, properly carried out, that many 
times, not only the lives and safety of 
other members of the family can be 
cared for, but also the extreme annoyance 
to the members of the family itself from 
having a case placarded which is not diph- 
theria avoided ; and I have no doubt that 
very many cases have been thus reported 
which were not diphtheria. I have seen 
many cases of tonsilitis with the tonsils 
completely covered with membrane from 
the coalescence of distinct follicles or folli- 
cular patches, which have recovered in 
the usual short time of a tonsilitis ; but if 
such case as that had furnished contagion 
for a family of four or five children, and 
had resulted in diphtheria to the rest of 
them after I had called it tonsilitis, I 
might have felt very much ashamed of 
myself. For this reason I would simply 
commend the examination of the exudates 
in this manner. 

Dr. F. E. Walbridge: I would like 
to have the doctor give us his methods of 
staining the bacillus. 

Dr. A. B. Farnham: The infecting 
poison is a ptomaine. The bacillus forms 
a slight layer and the ptomaine causes the 
fever, as I understand it. A practical 



July 30, 1892. 



Society Reports. 



185 



question came up to me once this summer. 
If you will notice at the commencement 
■of the disease, you will see a first glassy 
layer and if you treat that layer with a 
solution of chromic acid of sufficient 
-strength and penetration to destroy it, 
could not the case be cured? The only 
case of diphtheria that I have treated in a 
family here in Milwaukee was one in which 
I saw that very first infection, a small, 
.glassy layer. I happened to be treating a 
throat disease and it developed this, and 
on just that merest commencement I made 
a diagnosis which proved to be correct, 
and I have thought since that if that had 
been destroyed then and there, the whole 
difference might have been ended. Once 
this summer I saw that same appearance 
and I did treat it with chromic acid and 
at was the end of it. 

Dr. S. W. French: We might as well 
tell of our failures as our successes. It 
will be remembered that a few weeks ago 
I reported some possible cases of abortion 
vof diphtheria by the use of submucous in- 
jections of chlorine water. It was not 
very many days after that when I was 
-called to a case that had undoubted symp- 
toms of diphtheria, and I gave it a most 
thorough injection, and I used chlorine 
water that there was no doubt about what- 
soever. There was some doubt, I will 
say, in regard to the other cholorine wa- 
ter that I used after I had seen this. I 
gave that case an injection on two success- 
ive days and gave it very thoroughly, 
•but the case went from bad to worse and 
is now under the sod. Dr. Tower made 
the statement that the bacilli were found 
on the surface. Seibert, however, in his 
paper in the matter of the use of chlorine 
water, says that the bacilli are found in 
the sub-mucous layer and that is the rea- 
son he gives them the submucous injection 
-of chlorine water, to kill the bacilli in their 
•nest holes, so to speak. 

But there is one other point. Dr. 
Tower has said in his paper that it is, as I 
understand it, beyond a doubt established, 
that this so-called Klebs-Loeffler bacillus 
is the bacillus of diphtheria. I should like 
to know if that is a positive fact ; if it has 
been proved over and over again a sufficient 
number of times to establish beyond a 
doubt that it is the bacillus of diphtheria. 

Dr. W. H. A^ashburn : From my 
reading, it has not seemed to me as though 
the question of the aetiology or the mat- 



eries morbi of diphtheria was yet absolutely 
determined, although especially during 
the last two or three years the evidence 
seems to be growing stronger and stronger 
that the Klebs-Loeffler bacillus is the ma- 
teries morbi of the disease, yet if you will 
look over the files of the medical journals, 
you will find that a great many cases are 
reported that have presented all of the ap- 
pearances of diphtheria, both as to the 
course and termination and following par- 
alyses, and many cases also with the ele- 
ment of contagiousness present, where 
this peculiar bacillus has not been 
found. 

Dr. Tower referred to the cases of Ba- 
ginski. The impression that I derived 
from reading the report that I saw of that 
paper was somewhat different from the 
way he stated it in his paper. There were 
quite a number of cases that presented 
every appearance of diphtheria except that 
they did not contain these bacilli; and a 
certain number of those were fatal and 
were followed by paralysis of the pharynx, 
and I believe that those cases were cited 
to illustrate the fact that it was not so 
certain after all that the Klebs-Loeffler 
bacillus was the actual active agent in the 
disease; nevertheless the mortality among 
those cases was much less than among 
those in which this bacillus was present. 

I think that we would gain considerably 
if we were all of us expert enough with the 
microscope to be able to recognize these 
bacilli ; but I do not think that if I had 
Dr. Tower's paper as a guide and my 
microscope beside me that I would be able 
to make a satisfactory examination of the 
sputum. It does not seem to me as 
though he has gone sufficiently into the 
subject of the preparation and character- 
istics of the bacilli to enable one who is 
not already expert in the study of bacter- 
iology, to the discovery of this bacillus. 

Dr. A. J. Puls: I just want to make 
this point, that Dr. Tower stated that con- 
tagious diseases of the throat he classes al- 
ways as diphtheritic. It seems to me that 
I have seen a number of cases of ordinary 
tonsilitis which was just as contagious as 
diphtheria, although the disease appeared 
in a benign form ; so also coriza. 

Dr. U. 0. B. Wikgate: It is well 
known that we have a great deal of diph- 
theria in this city. During the past year 
1891, there were four hundred deaths re- 
corded, and usually where a death certifi- 



186 



Society Reports. 



Vol. lxvii 



cate comes in, it is pretty sure that the di- 
agnosis has been correctly made as diph- 
theria. Undoubtedly there are a great 
many cases of diphtheria reported that are 
not diphtheria, but I think that the phys- 
icians of the city as a rule are inclined to 
give the public the benefit of the doubt 
and report the cases. It is a commenda- 
ble practice, I believe, and unless there is 
some way of making a positive diagnosis, 
as Dr. Tower has stated in his paper, it 
seems to be the best course to pursue. 
Certainly it is much better to report a case 
that is not diphtheria than it is to fail to 
report a case that is genuine diphtheria, 
if we are to attempt to do anything in the 
way of prevention. There are certain wards 
of the city, I have noticed in looking up 
the records of the past year, that show a 
very marked dissimilarity in the propor- 
tion of the number of cases reported and 
the deaths. Some wards show a very large 
mortality compared with the number of 
cases reported and others a very small mor- 
tality. 

There are two questions I would like to 
ask Dr. Tower, one is, is it not well recog- 
nized that you may find bacillus of diph- 
theria in a throat that does not have diph- 
theria and which may recover without hav- 
ing diphtheria, or even in perfectly healthy 
throats ? The other question is in regard 
to the degree of temperature which will 
destroy the bacillus, which I do not quite 
understand ? 

Dk. F. J. Tower: In answer to Dr. 
Walbridge about the staining of these bac- 
illi, there is probably nothing easier to do 
in a microscopical way. All the necessary 
chemicals that are needed are a small 
amount of a Methyl blue, probably Grieb- 
er's blue is about the best that can be had; 
it can be made in an aqueous solution, or 
it can be made in what they call Loeffler s 
blue which is an extremely weak solution 
of caustic potash with the aniline dye dis- 
solved in it, making a saturated solution 
in alcohol; and when you want to use the 
staining material add five or six drops of 
the saturated alcoholic solution of the ani- 
line to a watch-glass full of water; pass 
your slide through an alcohol-flame or gas- 
jet two or three times to set the albumin- 
ous substances, then place it in your 
watch-glass of blue water and hold it over 
the burner or gas-jet and heat it until it 
steams; do that for two or three minutes 
or until you bring it to the boiling point, 



then let it stand for four or five minutes ;. 
take the cover-glass out of the blue solu- 
tion, wash it in water, put it proper side 
up on a slide and examine it immediately, 
pressing out the superfluous water. Prob- 
ably there is no easier thing to do than to 
make that examination. If you are in 
doubt as to the presence of the bacillus, 
take a potato, which need not be sterilized, 
put some of the exudate on it and keep it 
at about the temperature of the body, 
about thirty-eight degrees; leave it there 
for five or six hours or until the next 
morning, then take a little of this glassy 
film which forms. The Klebs-Loeffler 
bacillus under proper temperature grows 
with extreme rapidity, whereas other bac- 
teria that would interfere with our exam- 
ination do not, so that it is really unnec- 
essary to sterilize the media that we use- 
for examining or hunting for the Klebs- 
Loeffler bacillus, 

In answer to Dr. Farnham about the 
the ptomaine, as I understand it, I think 
the definition for the word ptomaine means 
alkaloidal-poison. According to the late 
experiments made with this substance pro- 
duced by the Klebs-Loeffler bacillus, it is 
not a true ptomaine, it is an albuminous 
substance. This glassy layer that the doc- 
tor spoke about is exactly what is seen on 
a potato or on gelatine. The finding ac- 
cording to Seibert of the bacilli in the sub- 
mucuous tissue I doubt. I have made 
lately some sections of diphtheritic mem- 
brane according to new processes and find 
that the bacilli are with possibly an except- 
ion or two, all contained in the outside, so 
that if we take a piece of membrane say 
one- eighth of an inch thick and properly 
stain it, when it is thoroughly washed out 
and held to the light, we will see a fine 
blue line in some cases where the bacilli are;, 
oftentimes they do not seem to be able to 
puncture through the membrane. Other- 
wise, why do not the bacilli enter the body, 
and it is a known fact that they do not. 
As far as the Klebs-Loeffler bacillus being' 
the cause of diphtheria is concerned, I did 
not know that there was any doubt about 
it, but there may be. As good men as I 
have quoted in my paper, men that are 
continually working on that subject, al- 
most no other subject, claim that it is a 
fact. My own experience has oeen limited > 
I have had a very few cases to examine 
actually, but in those cases where I have, as 
I state, I found the Klebs-Loeffler bacillus, 



July 30, 1892. 



Society Reports. 



187 



and where it was a case that had progressed 
considerably there were no other bacteria 
found at all. 

Dr. Washburn said that he had a differ- 
ent idea from a certain paper by Baginski. 
Baginski did in his article call out both 
sides of the question. My reference to 
that paper was only in this way, to the 
opinion of the other men present who were 
probably at this meeting in Berlin lately, 
some of the most eminent men there are 
in the world, and the general opinion ar- 
rived at seemed to be that a bacteriologi- 
cal examination was necessary, as I stated. 

In regard to not being sufficiently plain 
in my methods, I think I have covered 
that point now. About the contagious- 
ness of choryza and tonsilitis, that cer- 
tainly is possible; but the contagion that 
we have there as due to the streptococcus 
and the cephalococcus pyogenus due to 
pus microbes. I think Dr. Weurdemann 
will tell you, as I believe, that some cases 
of otitis media are contagious, and probably 
for the same reason. Dr. Wuerdemann, 
could not such a case of otitis media pro- 
duce an ophthalmia? 

Dr. H. V. Wuerdemann: Yes, sir. 
Otitis media, however, is contagious in- 
directly, i. e., the nasal affection disease is 
contagious ; and coryza is contagious, pro- 
ducing a purulent ear disease, then eusta- 
chian salpingitis, and after that, middle 
ear disease. 

Dr. Tower: In answer to Dr. Wingate 
about finding the Klebs-Loeffler bacillus 
in non-diphtheritic cases, I doubt if it is 
so found. It has been to my mind proven, 
where there is a considerable number of 
Klebs-Loeffler bacilli present, the sub- 
stance which they produce being a ferment, 
a minute quantity of it in the circulation 
seems to act as ferment, and that minute 
quantity it is necessary to have but a very 
small number of Klebs-Loeffler bacillus 
present to produce, so that if we had a 
case with any discoverable number of 
Kelbs-Loeffler bacilli in the throat, we 
would probably have some systemic effects 
also. I believe that some investigators, I 
could not name them now, have claimed 
that they found occasionally the Klebs- 
Loeffler bacilli in sputum, in faucial 
mucous, but there is, of course, in those 
cases where you find one or two, the possi- 
bility of not only their inability to discover 
them, but also it is very easy to make a 
mistake in the bacteriological examination, 



if everything is not absolutely and scrupu- 
lously clean, in which case you are bound to- 
have some kind of outside infection. 

In regard to the temperature necessary 
to destroy the Klebs-Loeffler bacilli, pro- 
bably it was a little bit misleading, as I 
used the centigrade scale. Exposure at a 
hundred degrees or boiling point is suffi- 
cient to destroy them. The Klebs-Loeffler 
bacilli themselves grow but very sluggishly 
at a temperature below 18 degrees centi- 
grade and do not grow above 58 degrees- 
centigrade which would be about 140 de- 
grees Fahrenheit. 

Dr. A. B. Farnham: I believe that 
the authorities state that an exposure to a 
temperature of 140 degrees for ten minutes 
will destroy the Klebs-Loeffler bacillus; of 
course a higher temperature is usually em- 
ployed, 200° or 250°. 

Dr. W. H. Washburn: The doctor 
spoke of the bacillus being present on the 
surface of this false membrane, and in his 
remarks he said — at least I so understood 
him — that if the bacillus was on the under 
surface of this false membrane, why didn't 
it get into the blood. We know that these 
bacilli do not get into the blood. Is it not 
a fact that these bacilli have been inject- 
ed subcutanously under the skin of the 
animals and yet have not got into the 
blood? If I am not very much mistaken, 
experiments of that kind have been re- 
peated time and again. The bacilli have 
been injected subcutaneously and still have 
not found their way into the circulation, 
but remained right where they were in- 
jected; and hence the objection that the 
bacilli were not on the under surface of 
the membrane, because they did not get 
into the blood, would not be tenable. 



SEPSIS OF THE UMBILICAL WOUND, 
Eross (Arch. f. Gyn., B. xii., H. 3) 
observed the process of healing of the 
umbilical wounds in 1,000 new-born in- 
fants under different modes of treatment. 
A strictly normal course was the exception 
rather than the rule. Morbid conditions 
of greater or less gravity were found in 
sixty-eight per cent. These consisted in 
sloughing of the stump, softening instead 
of complete mummification, decomposition 
of fragments left undetached after the 
rest had separated, suppuration and gan- 
grene. Pyrexia occurred in 220 cases and 
in a certain proportion of instances was 
the only evidence of septic absorption. 



188 



Selected Formulae. 



Vol. lxvii 



Selected formulae 

FOR HOARSENESS. 

In addition to the measures employed in 
ithe treatment of the causative condition, 
the following formula will prove useful in 
the amelioration of hoarseness : 

TX Acid, tannic 5j. 

JX Pulv. sodii biborat 5j. 

Tinct. capsici f5ss. 

Aquae rosa? fSx.— M. 

S.— To be used frequently as a gargle. 

._ —Whitla. 

FOR LARYNGEAL PHTHISIS. 

In the treatment of this affection, Cozzo- 
lino (Revista de Giencias Medicos de Bar- 
celona, April 25, 1892) employs this mix- 
ture : 

T> Pulverized iodoform 5 00 grammes. 

iX Powd. phosphate of calcium. 10.00 grammes. 

Boric acid, in powder 5.00 grammes. 

Menthol.. From 40 to 80 centigrammes. 

M. Sig.— To be insufflated into the larynx, night and 
morning. 

FOR SYPHILIS. 

The following mixture is recommended 
by Stukovenkoif and Balzer (Jour, des 
Maladies Cutan. et Syphlit., April, 1892), 
in the treatment of syphilis : 

TV, Benzoate of mercury 0.40 gramme. 

IX Iodide of potassium 20.00 grammes. 

Distilled water 25.00 grammes. 

Simple syrup 1000.00 grammes. 

M. Sig. — A dessertspoonful a day. 



THE USES OF RESORCIN. 

The therapeutic uses of resorcin are care- 
fully reviewed in II Raccoglitore Medico, 
April 30, 1892, and the following pre- 
scriptions recommended : 
For acute gastritis, dyspepsia, etc. 

TV Pure hydrochloric acid. 

±X Sublimated resorcin, of each 2.00 grammes. 

Syrup of orange peel 20.00 grammes. 

Distilled water 178.00 grammes. 

M. and place in a dark bottle. Sig.— A tablespoonful 
every two hours. 

Eor catarrh of the stomach : 

TV Infusion of rheubslfrb root 180.00 grammes. 

J-X Sublimated resorcin 3.00 grammes. 

Bicarbonate of sodium 8.00 grammes. 

Peppermint water 10.00 grammes. 

M. and place in a dark bottle. Sig.— A tablespoonful 
-every hour. 

For carcinoma of the stomach : 

TV Decoction of condurango 180.00 grammes. 

J-X Tincture of rheubarb 5.00 grammes. 

Sublimated resorcin 2.00 grammes. 

Syrup of orange peel 20.00 grammes. 

M. and place in a dark bottle. Sig.— A tablespoonful 
every hour. 

For sea-sickness : 

TV Sublimated resorcin 0.1 to 175 gramme. 

IX Sugar of milk 0.5 gramme. 

M. and make thirty papers. Sig.— A powder every 
hour. 



EARACHE. 

When due to inflammation of the exter- 
nal meatus, it is well to scarify first, and 
then to make use of aural suppositories or 
tampons, about one-third inch long, and 
composed of : 

Morphin . sulph. 

Cocain. hydrochlor aa cgm. 10. 

Gelatin grm. 90.— M. 

Or, the canal may he irrigated by 6 -per 
cent, solutions of cocaine, or 20-per cent, 
solution of carbolic acid in glycerin. 
— Giornale Internatz. delle Scienze Med. 



CAVAZZANFS ANTISEPTIC POWDER. 

To improve upon the antiseptic virtue 
of iodoform and at the same time to dimin- 
ish tendency to cause bleeding, Cavazzani 
( Wein Med. Presse) has devised the follow- 
ing: 

TV Iodoform P. 55. 

JV Salicylic acid P. 20. 

Bismuth subnitrate , P. 20. 

Camphor 5. 

This mixture has proven an excellent 
disinfectant and stimulant in cases of 
bubo. Its use must be suspended every 
fifth or sixth day, iodol being employed 
instead. 

SUPPOSITORIES OF MORPHINE AND CO- 
CAINE IN PERITONITIS. 

Dr. Klefer (Le Bulletin medical Xo. 44, 
1892), in order to combat the pain and 
vomiting of peritonitis, employs the fol- 
lowing suppository : 

TV Extract of opium i -- / , r , TMO R 

JX Hydrochlor. cocaine f aa c S ms - 6 - 

Iodoform { 

Cacao butter ) ^ 



NUTMEGS IN HAEMORRHOIDS. 

The common nutmeg employed in the 
form of an ointment is said to give prompt 
and permanent relief in itching and painful 
piles. It may be employed as follows : 

T> Pul v . nuc . moschat 5i j . 

-IX Acid, tannic .....5j. 

Petrolat ....Sj. 

■ M. Sig.— Apply locally. 

—Ex. 



CORYZA. 

TV Naphthalin in an impalpable powder. . 5vj. 
JX Powdered boric acid. . 5vj. 

Powdered camphor gr. xv. 

Extract of violets gr. xv. 

Essence of roses gtt. xx. 

Sig.— Mix and use as a snuff in coryza. 

— V Union Medicale Therap. Gazette, May 
16, 1892. 



July 30, 1892. 



Editorial. 



189. 



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Xeatnno Hrticles, 

CAEBOLIC ACID GAXGBENE. 

The profession has recently been warned' 
more than once through the unfortunate 
experience of surgeons that the use of 
carbolic acid solutions as a surgical dress- 
ing is frequently followed by grave com- 
plications, amounting in some cases to a 
condition of dry gangrene of the parts 
that have come in contact with the acid.. 
This complication may result when the- 
original injury is only trivial. The first 
symptom the patient will complain of is a 
numbness of the parts, or a prickling sen- 
sation, this is frequently followed by severe- 
pain, and upon removal of the dressing 
the parts below it will be found to have 
assumed a dark blue or black color, to be- 
without feeling, and in other words, to- 
present the typical picture of dry gan- 
grene. 

Billroth, the German surgeon, has some 
time since called the attention of the pro- 
fession to the danger attending the use of 
carbolic acid, and his warnings were quoted 
by nearly all the leading German medical 
journals. Strange to say, apart from the- 
histories of a few cases published by 
Kortum, no further mention has been 
made of the subject in German literature. 
Kortum sought to explain this unfavor- 
able action of carbolic acid, by crediting it 
to an" action upon the vaso-motor nerves. 

It has however, been the privilege of 
Dr. A. Frankenburger, of Nurenberg, in 
his able Inaugural Address before the- 
University of that city, to definitely settle 
the question of the cause, and to throw 
much valuable light upon the subject. His 
address has also been discussed editorially 
in a recent number of the Medicinische 
Neuigheiten. 

In France the subject has been widely 
discussed, and among French writers on 
the subject the dissertations of Tilleaux 
and Secheyron are perhaps most notable- 
It is evident that the conditions produced 



190 



Editorial. 



Vol. lxvii 



.are not merely the result of the cauterizing 
•effect of the acid, as suggested by Billroth. 

Frankenburger, to settle the question, 
-conducted a series of experiments upon 
.animals, the results of which appear to be 
most conclusive. He applied the acid in 
the form of a 3 per cent, or 5 per cent, 
solution upon a bandage covering the in- 
tact skin of the animal. The parts over 
which the bandage was placed were shaved, 
and the dressing kept constantly moist 
with the solution. Every half hour micro- 
scopical examinations of a portion of the 
skin were made, and the experiments 
lasted for about three hours in each in- 
stance. 

In every case atypical ^mummification" 
of the skin was observed, which gradually 
encroached upon the deeper tissues the 
longer the application was continued. The 
microscopical appearances of the prepara- 
tions were very characteristic and similar 
in every case. 

The epidermis was destroyed, and the 
papillae of the chorium were laid bare; 
there were large gaps in the connective 
tissue due to an enlargement of the lymph- 
atics; the lumina of the vessels were filled 
with a partly yellowish red and partly 
yellowish white masses, — viz., vascular 
thrombi. 

That these thrombi are really formed 
intra vitam during the course of the ex- 
periments, is proven by the results of many 
authors who have studied the action of 
•carbolic acid upon the blood, among whom 
we may mention, G. G. Bill, Huchs, 
Prudden and Hueter. These writers have 
observed as an action of the acid a change 
•of the blood corpuscles, consisting in a de- 
generation of the red corpuscles and acces- 
sion of the amoeboid movements of the 
leucocytes. This has been shown by direct 
examination of the mesentery of a 
curarized frog, as a direct action of the 
acid. Frankenburger's experiments show 
that a similar action is obtained by the 
mere application of dressings moistened 



with a weak carbolic acid solution. He 
summarizes the results of his experiments 
as follows : 

If parts of the human body, intact or 
else having slight injuries, be brought in 
contact with a carbolic acid solution of 2}4 
or 2 per cent, strength, the action of the 
acid will in predisposed cases cause a 
gangrene of these parts extending as far 
as the application. 

This gangrene assumes the typical ap- 
pearance of dry gangrene. It is caused 
by the formation of thrombi in the vessels, 
and if the application be kept up for a 
sufficient length of time will result in an 
entire occlusion of all the vessels in the 
field of contact, thus robbing the parts of 
all nutrition. 

This thrombosis and subsequent occlu- 
sion is directly caused by the degenerative 
action of carbolic acid upon both the red 
and white blood corpuscles. There are no 
circulatory disturbances of note caused by 
the action of the acid upon the vaso- 
motor nerves. 

The longer the acid is allowed to remain 
in contact with the parts, the deeper the 
gangrene will spread. 

This action is especially frequent in 
such parts as are entirely surrounded by 
the dressing — notably the phalanges of the 
extremities. 

The use of carbolic acid in the form of 
moist dressings is especially prone to cause 
gangrene. 

The danger of carbolic acid gangrene is 
especially predominant in' weak subjects, 
women and children. 

In conclusion, we would infer from the 
results of these observations and experi- 
ments that the use of carbolic acid as a 
dressing in minor or major surgical opera- 
tions should be restricted as much as pos- 
sible, and other equally efficacious antisep- 
tics substituted ; and, finally, that the pro- 
fession should warn the laity against the 
indiscriminate use of the drug in the treat- 
ment of injuries. 



July 30, 1892. 



Book Reviews. 



191 



Book Reviews. 



TREATISE ON MEDICAL AND SURGICAL 
GYNAECOLOGY . By S. Pozzi, M. D., Pro- 
fesseur Agrege a la Faculte de Medicine 
Chirurgiende l'HopitalLourcine-Pascal, Paris. 
Complete in Two Volumes. Translated from 
French Edition under the supervision of, and 
with additions by, Brooks H. Wells, M. D., 
Lecturer on Gynaecology at the New York 
Polyclinic ; Fellow of the New York Obste- 
trical Society, and the New York Academy 
of Medicine. Volume Two. With 1T4 
wood-engravings, and 9 Full-page Plates in 
Color. Royal Octavo. 174 wood -cuts. Mus- 
lin, $6.00; sheep, $7.00; half morocco, $8.00. 

The first volume of Pozzi's Gynaecology 
was favorably noticed in these columns 
some months ago. Volume second fulfils 
all the expectations raised by its prede- 
cessor. Undoubtly the work will take 
rank as the leading exposition of modern 
gynaecology. It is not to be expected 
that every theory and every statement of 
the author will find acceptance ; but his 
book is so comprehensive, progressive, and 
so distinctively fresh and modern that it 
must gain universal favor. It is refresh- 
ing to find many untenable theories of the 
older authors (especially as to the pathol- 
ogy and therapeutics of pelvic imflamma- 
tion and extra-uterine pregnancy) ignored, 
and instead to find modern theories based 
upon the facts proved by the experience of 
the past twenty years. Gynaecology has 
developed so marvelously during this time, 
and the mass of facts accumulated has been 
so great, that it is now possible to write a 
scientific treatise upon this subject. It 
is no longer possible to sustain theories 
either as to pathology or treatment upon 
reputation of their discoverers and pro- 
mulgators. Hence we can chronicle the 
passing away of the but recently accepted 
theories concerning pelvic inflammation, 
cellulitis, pelvic abscess, hematocele, 
displacements of the womb, the perineal 
body, etc. 

Chapters I-IV deal with the many and 
complex problems of pelvic inflammation 
in a manner which will find approval with 
all who have had opportunities for studying 
the subject not only clinically but also by ab- 
dominal section. Special statements will, 
of course, be challenged, but on the whole 
we know of no exposition of this sub- 
ject equally good. The author regards 
sepsis in childbed and gonorrhoea as the 
great causes of pelvic inflammation. He 
considers also that almost without exception 



the extension of the inflammation takes 
place along the mucous lining of the uterus 
and tubes, and yet he distinctly upholds 
the doctrine that at times — especially if 
not exclusively during the puerperal state 
— extension takes place along the lymph- 
atics. The doctrine is laid down in posi- 
tive terms that salpingitis is precedent to 
and a part of almost every case of peritoni- 
tis; and this is emphasized by treating the 
subject under the title per imetro- salpingi- 
tis. The innovation is to be commended, 
as fixing upon the mind of the student the 
fact that almost without exception salpin- 
gitis precedes, causes, and is a part of pel- 
vic peritonitis. The strictly minor role 
of inflammation of the pelvic cellular tis- 
sue also is amply elaborated. It occurs 
at times as a result of puerperal infection. 
This is the usual form. It occurs also as 
a result of inflammation of the uterine ap- 
pendages. Pozzi also admits (but gives 
no proof) that it occurs as a result of dirty 
operations upon the uterus. In view of all 
the facts proof should have been forthcom- 
ing for this statement to gain credence. 
Well-observed cases, with autopsies, as for 
instance those reported by Coe, of the 
Woman's Hospital in Xew York, of deaths 
from septic inflammation following opera- 
tions on the uterus, show that in such 
cases the inflammation spreads to the peri- 
toneum through the Fallopian tubes. The 
portion of these very excellent chapters 
most open to criticism is that relating to 
the treatment of pus in the pelvis. The 
author admits the propriety of simple in- 
cision of the pus collections under several 
conditions — at the same time admitting the 
danger and deficiencies of the method. 
Manv excellent gvnaecoloarists absolutely re- 
ject such measures, and treat all such cases 
by cceliotomy ; others probably with greater 
wisdom reserve incision for cases of broad 
ligament abscess, or suppurating haema- 
toma — both rare conditions — and certain 
cases of pelvic abscess when the patient is 
exhausted and suffering from general sep- 
sis. In the last class of cases by evacua- 
ing the pus the patient can at times be 
improved so as to withstand the shock of 
a radical operation to remove the abscess 
sac. 

Chapters V — IX treat of tumors of the 
uterine appendages, broad and round liga- 
ments. The treatment of these subjects 
is satisfactory, but conventional. Chap- 
X is devoted to genital tuberculosis, and 



192 



Periscope. 



Vol. lxvii 



Chapter XI to haeinatocele. Unfortunately 
this was written before the general accept- 
ance of the fact that most cases of haema- 
tocele are cases of ruptured tubal preg- 
nancy. The author advises the policy 
of doing nothing, which is clearly inad- 
missible because of the dangers of recur- 
rent and fatal haemorrhage. While it is 
true that cases of haematocele recover un- 
der the expectant treatment, it is none the 
less true that very many die from further 
haemorrhage. Fortunately abdominal 
section in good hands w T ill save almost 
every case. 

Chapter XII covers the subject of ectopic 
gestation admirably. The author every- 
where takes advanced ground. The work 
of the past is chronicled and due praise 
given to the many who have added to our 
knowledge of this subject. But great ad- 
vances are predicted for the future. The 
currently accepted pathology in given, 
primary abdominal and ovarian pregnancy 
being admitted. But these are regarded 
as most rare, and due caution is exercised 
in accepting doubtful examples. Werth's 
view that an ectopic gestation should be 
regarded as a malignant tumor, to be re- 
moved promptly after its discovery, is 
commended. Prompt removal of the 
gestation sac is advised in all cases before 
the fifth month ; injections of morphia, 
and electricity are condemned, as being 
uncertain if not unsafe. The dangers in- 
herent in the condition are considered 
greater than those of the operation. It is 
gratifying to find such sound doctrines 
taking vigorous root in French soil. 
Prompt operative interference is advised 
also for the later months. The dangers 
of haemorrhage and septicaemia being 
regarded as greater that those of an 
operation. It is pointed out that recent 
operations have been much more success- 
ful than older ones. Thus up to 1886 
Harris reports thirty sections done during 
the viability of the child with five mothers 
and sixteen children saved; whereas since 
that date of thirteen cases, nine women 
and eleven children were saved. Much 
is expected from prompt operation with a 
perfected technique. The author states, 
" here, as in all the problems of abdomi- 
nal therapeusis, the theoretical objections 
of a timid surgeon fall before the results 
of a bolder practice characterized by good 
technique." The results under expectant 
treatment until after false labor having 



been so deplorable, the courageous sur- 
geon will be emboldened to apply his art 
for the relief of these women in such peril 
of their lives. With modern haemostatic 
forceps and an abundance of gauze for 
packing, the skillful surgeon should be 
able in most cases to successfully remove 
the gestation sac and add another triumph 
to abdominal surgery. Cases in which the- 
placenta grows from the intestines will 
probably remain a dangerous class to deal 
with. 

Chapters XIII— XXIII deal with di- 
seases of the vagina, vulva and perineum. 
Chapters XXIV — XXVI treat of mal- 
formations of the genital organs and 
Chapters XXVII— XXVIII of diseases of 
the urinary tract, rectum, and pelvis, 
thus giving the book a wider scope than is. 
usual with treatises upon gynaecology. 



periscope. 



THERAPEUTICS. 



TINCTURE OF IODINE IN INFECTIOUS 
ULCERS OF THE CORNEA. 

Chibret (Rec. cVophthal., September,. 
1891) thinks he has found in tinctures of 
iodine the following necessary properties :. 
1. A powerful and general antiseptic 
action. 2. Energetic dialytic power. 3. 
Absence of formation of insoluble salts 
causing indelible opacities of the cornea. 
4. Non-destructive effect on the cornea. 
He thinks his belief in the value of this 
drug has been fully justified by ihe results, 
and he even recommends its use in corneal 
scars and opacities. 



TREATMENT OF THREAD WORMS. 

Heath (British Medical Journal, Decem- 
ber 10, 1891, p. 1300) writes that within 
the last few years the views about ascarides 
have greatly altered. It used to be thought 
that they lodged entirely in the rectum, 
and that the patient could be cured by 
copious enemata, usually of salt and water. 
But it has been shown within the last few 
years that it is not a fact, and that these- 
ascarides have their habitat mainly in the 
caecum, and are to be found, more or less, 
throughout the whole length of the large 
intestine. It must, then, be borne in 
mind that it is not sufficient to atta3k the 
rectum with enemata, but purgative medi- 



July 30, 1892. 



Periscope. 



193 



cine must also be given which shall act 
upon, the caecum and clear away the worms 
themselves and the mucous in which they 
are lodged. You may often see them com- 
ing away in large balls as the result of 
purgative medicine, and until they are 
thoroughly cleared out you cannot hope to 
cure the patient. 



CANTHARIDINATES IN TUBERCULOSIS. 

Demme (Therap. Monatsh., March, 
1892) has treated 30 cases by subcutaneous 
injection. The potassium salt was used 
at first, but the sodium preparation gave 
rise to less pain. There was never any 
suppuration at the site of the injection, 
but iii one case a considerable swelling oc- 
curred without any reddening of the skin. 
It took long to subside. The dose used 
was 0.0001 to 0.0002 g. In 10 cases of 
more or less severe laryngeal with pulmon - 
ary tuberculosis no conclusion could be 
formed owing to the insufficient length of 
the treatment. After giving short details 
of the remaining 20 cases, the author 
makes the following remarks : Results are 
obtained by this treatment more surely 
than by any other method. The drug 
must be used with great caution, for al- 
buminuria appeared in every case. This 
albuminuria lasted longer than the treat- 
ment in 5 cases. The effect on the lungs 
is slight, but expectoration becomes 
easier. In the larynx the oedema, especi- 
ally that over the arytenoid cartilages, dis- 
appears almost completely. More solid 
infiltrations also tend to become smaller 
more quickly than under other treatment. 
While some cases were greatly improved 
and might (if the albuminuria could be 
avoided) be looked upon as cured so far as 
the larynx was concerned, two were cer- 
tainly cured. In other cases temporary 
improvement alternated with relapse. — 
Brit. Med Jour. 



LOCAL APPLICATION OF * CALOMEL IN 
INFLAMED HEMORRHOIDS. 

Dr. B. James (La Semaine Medicale, 
No. 11, 1892) has employed with success 
for several years the local application of 
calomel in inflamed haemorrhoids. The 
remedy is applied topically by the fingers 
to the swollen and inflamed parts. This 
rapidly causes all the morbid symptoms to 
disappear. The writer has not seen a sin- 
gle case resist the action of this remedy. 



MEDICINE. 



EMIGRATION OF LEUCOCYTES FROM 
THE TONSILS. 

Dr. Polyak finds that most of the leu- 
cocytes which in a normal condition of the 
tonsil migrate through its epithelium into 
the buccal cavity are lymphatic corpuscles 
(lymphocytes) — that is to say, young ele- 
ments generated by karyokinesis of the 
cells of the adenoid tissue. There are, 
however, in addition, a considerable num- 
ber of leucocytes with polymorphic nuclei 
which migrate from the superficial capil- 
laries and capillary veins. The emigration 
of these multi-nuclear leucocytes is also 
observed in places where there is fibrous 
connective tissue beneath the epithelium. 
The emigration of large numbers of lymph- 
ocytes is accompanied by well-marked 
destruction of epithelium close to the free 
surface, but the emigration of the multi- 
nuclear leucocytes only appears to give rise 
to increased exfoliation of the superficial 
epithelial cells. When acute inflammation 
of the mucous membrane was induced by 
irritation with chemicals, the emigration 
through the many layers of flattened 
epithelium was mainly confined to multi- 
nuclear leucocytes. — Lancet. 



ON THE KNEE-JERK IN THE CONDI- 
TION OF SUPERVENOSITY. 

Dr. T. Hughlings-Jackson makes a 
short preliminary communication on this 
subject in the British Medical Journal, 
1892, No. 1624. He has observed absence 
of knee-jerks in some cases of emphysema 
with bronchitis, where the blood has be- 
come venous in an extreme degree. As 
the patients observed were near death, he 
hesitates to conclude that they were absent 
as a mere consequence of supervenosity. 
He quotes the case of a girl of nine years 
suffering from diphtheria, who was trach- 
eotomized at midnight for urgent respira- 
tory difficulty, producing cyanosis. Be- 
fore the operation her knee-jerks were 
absent. On the following day, the cyano- 
sis having then disappeared, the jerks 
were obtained and remained present until 
her discharge from the hospital. The 
knee-jerks of a dog artificially asphyxiated 
by clamping the trachea were absent in the 



194 



Periscope. 



Vol. Ixvii 



third stage of asphyxia, having been exag- 
gerated in the earlier stages of the condi- 
tion. It is suggested that the preliminary 
exaggeration was owing to the loss of cere- 
bral control over the lumbar centres, the 
eventual loss being occasioned by the suc- 
cumbing of these strongly organized spinal 
centres to the poisonous influence of super- 
venous blood. 

The testing of knee-jerks before and 
after the administration of oxygen to 
cyanosed patients may be expected to 
throw light on the question. If superven- 
osity is a cause of loss of knee-jerks, that 
fact may be important in the apoplectic 
state, and possibly somewhat with regard 
also to post-epileptic coma. Careful obser- 
vations on such cases may be productive of 
valuable results. 



ANKYLOSTOMIASIS THE BERIBERI OF 
ASSAM. 

According to the Indian Medical Gaz- 
ette for February, 1892, Dr. G. M. Giles 
finds that the disease known as the beriberi 
and the kala-azar of Assan are identical, 
and that they are in reality ankylostomiasis 
caused by the DocJimius duodenalis. This 
parasite, Dr. Giles finds, develops slowly 
if at all in drinking-water, but develops 
plentifully in faeces. The ingress of the 
parasite into the human system is believed 
to be due to the habit of cleansing kitchen 
and table utensils with infected earth, and 
of eating food from a mat on the ground. 
The symptoms and causation of the dis- 
ease are the same as those found by Dr. 
Kynsey in the so-called beriberi of Ceylon. 



THE CEREBRAL CIRCULATION DURING 
HYPNOSIb. 

Drs. Sarlo and Bernardina (Rev. Speri- 
mentale XVIII, III), publish an article 
on this subject in which they discuss some 
of the physiological literature and elabor- 
orately report a case in which they were 
able to make a careful study of the cere- 
bral pulse through an aperture in the skull 
due to an old traumatism, and their paper 
is illustrated by sphygmographic tracings. 
The authors conclude as follows: (1) The 
cerebral circulation is different according 
to the hypnotic conditions, it appears that 
there may be hyperemia in the reduced 



lethargic state and ansemia in the thus in- 
duced cataleptic condition. (2) Every- 
thing leads us to believe that antagonism 
between the cerebral and the peripheral 
circulation, during tne hypnotic state does 
not exist. (3) A greater frequency and 
an apparent increase of the respiratory os- 
cillations are observable in the hypnotic 
condition. (4) The psychic functions, 
during the hypnotic conditions, incite a 
vascular reaction, identical with that 
which occurs in the normal state, but less 
marked on account of the existing vascu- 
lar constrictions. (5) The hypnotic state 
should not be considered as anything by 
itself, but serves only to put in evidence 
what already exists. The hypnotic manip- 
ulation, of whatever kind (sensory stimu- 
lation, suggestion, etc. ) has only the effect 
to increase the excitability of such nerve 
centers that are, as it were, the locus mi- 
nor is resistentive, and detach or function- 
ally cut off certain nerve elements from the 
complex that forms the organic substratum 
of the healthy mind. In our case the 
cortical motor elements, morbidly excita- 
ble, were, through the hypnosis, separated 
from the rest. 



SURGERY. 



PARTIAL NEPHRECTOMY AND REUNION 
OF RENAL PARENCHYMA. 

Tuffier (Archiv. Gener. de Med., July, 
1891). Renal cysts are frequently mis- 
taken for ovarian cystoma. Of these, the 
unilocular are benign in opposition to the 
multilocular ones. In the former the 
renal parenchyma is sufficiently extensive 
as to leave no doubt as to the desirability 
of preserving the organ as functionally use- 
ful. Complete nephrectomy, it has been 
heretofore held, offers a better chance of 
recovery in these cases of renal cysts than 
incision. The discouraging results in this 
operation, however, led the author to in- 
stitute a series of experimental studies 
(Gaz. Hebd., 1888, 1890, Arcliiv. Gener 
de Med., 1891), which developed the fact 
that haemorrhage from the renal paren- 
chyma may be controlled by compression 
of the vessels of the hilum and suture of 
the renal tissue. Such renal wounds heal 
readily and fistulse are only observed to 
occur in cases in which the ureter has been 
injured. He therefore proposes to care- 
fully dissect only the renal cyst, and to 



July 30, 1892. 



Periscope. 



195 



suture carefully the walls of the cavity in 
the substance of the kidney. This pro- 
cedure was carried out successfully in a 
case communicated by T. After enuclea- 
tion of the cyst the renal tissue was sutured 
by deep catgut sutures, the capsule being 
sutured separately, haemorrhage ceasing as 
soon as this was accomplished; no drain- 
age was employed. The wound healed 
kindly. In this case an epithelioma of 
the bladder was subsequently removed by 
suprapubic cystotomy. The subsequent 
fate of the patient is not recorded. 



EUROPHEN IN SURGICAL DRESSINGS. 

The respective advantages of dry and 
moist dressings have received much atten- 
tion of late. A point was made concern- 
ing dry dressings which did much to 
decide operations in their favor. We refer 
to the quality possessed by some of them 
of adhering closely to exposed surfaces 
thus making an impervious, antiseptic 
covering, beneath which the reparative 
processes may uninterruptedly take place. 
This adhering property is observed in a 
marked degree in europhen, which has 
attained a high reputation as a cicatrisant. 
Europhen, too, is a bulky powder which 
may be spread to advantage over large de- 
nuded surfaces in cases in which it would 
be dangerous to employ iodoform. The 
antiseptic and stimulating properties to 
europhen have, no doubt contributed 
greatly to its success, for its cresolic com- 
ponent promptly shows a characterisfic 
action. The iodine contained in europhen 
goes off slowly, thus preventing the toxic 
action so often recognized in preparations 
of iodoform, and making frequent dressing 
necessary, while its solubility in the liqui- 
fied products of inflammation add to its 
effectiveness as well as its safety. In the 
lesions of syphilis, in ulcerated surfaces, 
burns and all traumatisms, this new dress- 
ing has done admirable work. Europhen 
has undoubted advantage over iodoform in 
being free from disagreeable odor or toxic 
influences. 



IMPROVEMENTS IN THE ELECTRO-EN- 
DOSCOPE. 

Dr. Oberlander (Archiv fur Derm, und 
Syph., 1892, III. Heft.) gives an account 
of some improvements which have been 
devised as a result of suggestions furnished 



by a more or less constant use of the endo- 
scopes of Nitze and Leiter. 

The most important improvement seems 
to be a substantial enlargement in the 
caliber of the tubes used. Formely only 
instruments with a caliber of 22 to 24 F. 
was employed. It was found, however, 
that in a large proportion of the cases ex- 
amined tubes of 28 to 30, and even 32 F., 
could be introduced. As these yielded a 
much larger field of vision and better illu- 
mination, their use was found to be of 
great clinical value. 

The advantages to be derived from prac- 
ticing internal urethrotomy, under guid- 
ance of the .eye, by means of improved 
endoscopic instruments, are spoken of and 
the apparatus described and illustrated. 
(This procedure was, however, first de- 
scribed and practiced by Dr. F. Tilden 
Brown, of this city, who demonstrated its 
practicability and exhibited his instruments 
before the Genito- Urinary Section of the 
N. Y. Academy of Medicine, some six 
months before the publication of this 
paper.) 

The writer is of the opinion .much may 
be expected from the employment of elec- 
trolysis and the direct application of the 
galvano-cautery, in stricture and hyper- 
trophic disease of the urethra: and his 
appliances for carrying out these sugges- 
tions are also described among the more 
recent improvements. Considerable ad- 
vantage has been gained in deep urethral 
endoscopy by the employment of the 
hinged-obturator which enables the ob- 
server to introduce the straight tube to 
the membraneous urethra without pain or 
difficulty. 



OBSTETRICS. 



COMPLETE RUPTURE OF UTERUS. 

Winter (CentralM. f. Gyndk. , No. 1, 
1892) exhibited a uterus before the Berlin 
Obstetrical Society not long ago. A rent 
passed obliquely through the anterior 
walls, and reached from the contracting 
ring nearly to the os externum. The 
serous coat was divided as far as the level 
of its firm attachment to the muscular 
tissues, so that there was communication 
with the peritoneal cavity through a rent 
nearly 4 inches long. At the necropsy, 
the uterus was found strongly anteflexed, 



196 



Periscope. 



Vol. lxvii 



and the intestines and parieties had already 
(within 28 hours) adhered around the 
rent so as to cut it off from the peritoneal 
cavity. The patient was a 3-para, aged 
29 ; one labor was normal, one required 
forceps. The third was at term, and began 
naturally. In ten hours the water broke 
and the pains ceased. About nine hours 
later, rupture of the uterus occurred, the 
head slowly receded from the pelvis, and 
a trifling amount of flooding took place. 
The patient was sent into a lying-in hospi- 
tal. Winter found that the child had 
entirely escaped into the abdominal cavity, 
and lay in the first position, close under 
the parietes. The temperature was normal, 
the pulse 124; there was evidence of peri- 
tonitis, but not of severe haemorrhage. The 
indication was, he thought, to deliver at 
once, rather than to take steps to check 
haemorrhage. He did not deem it advis- 
able to attempt to deliver through the 
rent and out of the vagina, as the foetus 
lay far from the uterus, and the rent, if 
enlarged, would be the source of fresh 
haemorrhage. He made a short incision 
through the abdominal walls, and drew 
out the foetus and placenta within ten 
minutes. There was but little collapse ; 
the symptoms of peritonitis subsided for 
awhile after the operation, but soon reap- 
peared, and the patient died in twenty- 
eight hours. Nevertheless, Winter holds 
that the simple operation which he per- 
formed was preferable, in cases where 
little haemorrhage or fear of haemorrhage 
existed, to the long, difficult, and compli- 
cated, suturing of the uterus in abdominal 
section. The following table gives the 
results of thirty-seven cases of rupture of 
the uterus, with complete escape of the 
child into the peritoneal cavity : 



Treatment. 


Number. 


Deaths. 




5 
8 

1 

12 

7 
4 


5 

5 

1 

4 

5 
4 


Abdominal section after delivery 

Abdominal section, and delivery- 
through incision ; no suturing of 


Abdominal section and delivery- 
through incision; suture of uterus. 

Total 


37 


24 



Thus delivery through a simple incision 
in the abdominal walls gives a percentage 
of 60 for recoveries. — British Medical 
Journal. 



GYNECOLOGY. 



DIABETES AND THE FUNCTIONS OF THE 
. FEMALE ORGANS. 

Strojinowski ( Nouv. Arch. oV Obstet.etde 
Gynec, March, 1892, Supplement.) on 
the basis of eleven cases under his own ob- 
servation, states that diabetes not only 
causes suppression of the catamenia, but 
also distinct atrophy of the uterus and 
ovaries. 



CIMICIFUGA IN THE TREATMENT OF 
DYSMENORRHEA AND OVARIAN 
IRRITATION. 

Following the example of Boddie, of 
Edinburgh, Dr. James Brunton has em- 
ployed blacksnake-root in the treatment of 
dysmenorrhea and ovarian irritation. He 
employed 30-minim doses of the tincture 
thrice a day, and was able to dissipate the 
occipital headache and ovarian pains from 
which his patient suffered. t In cases of 
dysmenorrhoea, similar doses every four 
hours produced great benefit. 

Brunton believes that the drug is an ano- 
dyne, which is valuable as a substitute for 
the bromide sand opiates in dysmenorrhagic 
pain. 

When given for dysmenorrhoea, it should 
be given four days before, and continued 
over the period. 

In metrorrhagia, and menorrhagia, he 
believes it is a regulating agent, although 
it is sometimes disappointing in its action. 
— Practitioner, April, 1892. 



HYSTEROPEXY. 

Ohaput (Annales de Gynec. etd* Obstet. , 
April, 1892) discusses the treatment of 
uterine retroflexions. In simple retroflex- 
ion where the uterus is freely movable, 
the pessary is sufficient, though the curette 
may be needed ; but in more advanced re- 
flexions where the pessary cannot be used, 
abdominal section is needed. This pro- 
ceeding is preferable to vaginal hystero- 
pexy, as it allows the operator to choose 
between simple replacement of the uterus, 
removal of the appendages with or without 
fixation of the uterus (abdominal hystero- 
pexy), and fixation without castration. 
As fixation of the uterus itself is not in all 
respects advisable, Chaput recommends that 
the pedicles of the amputated appendages 
be fixed to the abdominal wound, or that 
the round ligaments be shortened, if re- 



July 30, 1892. 



Periscope. 



197 



moval of the appendages be inadvisable. 
In the discussion on this communication, 
P. Petit advocated Alexanders operation. 
He said that it had fallen into discredit 
owing to the many indications for thorough 
treatment of complications in each case. 
It sometimes proved necessary, he declared, 
to perform, at the same sitting, curettage, 
plastic amputation of the cervix, anterior 
colporrhaphy, colpoperineorrhaphy, and 
shortening of the round ligaments. 
Chaput objected that it was impossible to 
diagnose all the complications which in- 
terfered with the success and value of 
Alexander's operation without an abdom- 
inal exploration, which at once altered all 
the conditions associated with that opera- 
tion. Petit did not think highly of hy- 
steropexy. In one case, performed by a 
good operator, the pains from which the 
patient had suffered continued, and a bad 
ventral hernia developed. In another the 
patient was sick on recovering from chlo- 
roform, and the vomiting caused the 
threads to cut their way through the 
uterine tissue into which they had been 
passed. The patient died of haemor- 
rhage. — Brit. Med Jour. 



ENDOTHELIOMA OF THE OVARY. 

Rosthorn (Archiv fur Gyndkologie, Band 
xli., Heft 3)describes and figures the ap- 
pearances observed in microscopical sec- 
tions of so-called endothelioma, which he 
regards as a true neoplasm, favoring the 
term "sarcoma perivasculaire'' applied to 
it by Ackermann. He thinks that capill- 
ary stasis is doubtless an aetiological factor 
in its development. Several forms of endo- 
thelioma may be distinguished according 
to their mode of origin and the prevailing 
histological structure. 



PEDIATRICS. 



ACUTE CHOREA, WITH FATAL ENDOC- 
ARDITIS. 

Stahl, (Annals of Gyncec. and Pwdia- 
try, Phila., 1891, v., 183.) gives the fol- 
lowing case : 

C M., female, aged six. Family his- 
tory free from any neurotic tendency, or 
other discoverable predisposition to dis- 
ease. For a week or ten days before seek- 
ing medical advice, she had complained of 
her legs and feet being asleep, the "numb 
feelings " seemed to be confined to the 



lower extremities and not referred to the 
articulations. 

On May 19, 1891, she was pale, had 
moderate fever (101°), pulse 130, small 
and somewhat irregular in rhythm, tongue 
coated, stomach irritable, frequent vomit- 
ing, bowels constipated, some cough. 
There were small moist rales over both 
lungs with no impairment of resonance. 
There was presystolic and systolic mitral 
murmur, without increase in cardiac area. 
There was considerable dyspnoea. Three 
days later there developed a mild chorea, 
most marked on the right side. It reached 
its greatest severity and rapidly subsided. 
The dyspnoea, meanwhile, increased and 
the pain about the heart became more se- 
vere. By the twelfth day the choreic 
movements were no longer present, the 
dyspnoea now amounted to orthopnoea, 
the murmur had not changed in character, 
there was puffiness about the extremities, 
and the lungs were more congested. The 
child died the twentieth day from my first 
visit of heart failure due to dilatation. 
No autopsy allowed. 



INFANTILE MELANOSIS. 

A rare case of melanosis of the lower jaw 
in an infant is recorded in the current 
number of the Annals of Surgery by 
Charles A. Power, of New York. The 
child was three months old when it came 
under observation. The swelling was 
about the middle of the left side of the 
gum of the lower jaw, and in size about 
that of a small almond, ; oval, of moderately 
firm consistency and covered by mucous 
membrane which was apparently normal. 
An exploratory incision was made which 
yielded no pus. At the end of a month; 
when the child was again brought to the 
hospital, the swelling had much increased 
in size. It projected well beyond the 
middle line of the mouth, pushing the 
tongue far to the opposite side. It was 
dense, and firmly attached to the body of 
the jaw, which, when felt externally, was 
much enlarged and resistant. Ultimately 
the left half of the jaw was removed under 
chloroform. Jhe ordinary incision along 
the lower border of the bone was used, 
the body divided a little to the right of 
the symphysis, and the condyle dissected 
from the glenoid cavity. The operation 
occupied a little over an hour. The patient 
took the anaesthetic badly, failed to rally, 



198 



Periscope. 



Vol. lxvii 



and died two hours after being returned 
to the ward. On microscopic examination 
the tumor proved to be a true melanotic 
growth, springing from the periosteum of 
the lower jaw. The author adds that the 
patient would have had a better chance of 
life had time been taken up in operating. 
But in so young a subject such a proced- 
ure as was carried out would in any case 
have proved one of a very formidable 
nature. 



SULPHUR IN THE TREATMENT OF CHLO- 
ROSIS. 

Prof. Hugo Schulz [Med. Neuiglceiten^ 
No. 17, 1892) recommends sulphur in 
cases of pure chlorosis where iron has no 
action. In such cases the general condi- 
tion is much improved by the administra- 
tion of sulphur. After this drug has been 
given for a time the use of iron may be begun 
and successfully carried out. On the con- 
trary, it is not well borne in catarrhal and 
inflammatory states of gastro-intestinal 
tract. The form of administration is : 

T>. Flowers of sulphur 5 ijss. 

-TV Milk, sugar 5 xxv. 

Sufficient for ten powders. A knife- pointful three 
times a day. 

HYGIENE. 



STOP SPITTING. 

Says Dr. T. M. Prudden:— "If the 
vile and increasing practice of well-nigh 
indiscriminate spitting goes unchecked 
in nearly all assembling places and public 
conveyances ; if the misguided women who 
trail their skirts through the unspeakable 
and infectious filth of the street are to be 
admitted uncleanzed into houses and 
churches aud theatres; if theatres and 
court-rooms and school-houses and cars 
are to remain the filthy lurking-places of 
contagia which their ill ventilation and 
their mostly ignorant and careless so-called 
cleaning necessarily entail ; if in sleeping- 
cars and hotel bedrooms the well are to 
follow consumptives in their occupancy 
without warning, or even the poor show 
of official disinfection ; if in ill-ventilated 
and ill-cared for dwellings the well must 
breathe again and again the dust borne 
seeds of tuberculosis; if no persistent warn- 
ing is to be given to the ignorant of the 
dangers which lurk in uncleanliness — then 
our task will be most complex as well as 
difficult in limiting the contagiousness of 
tuberculosis." 



Of course cleanliness and plenty of water 
are necessary, but, after all, it is the ex- 
pectoration which carries the germ and 
promotes the spread of disease. Spitting, 
it seems, is not only a vile, but an increas- 
ing habit. This is an unfortunate social 
fact which reformers do not seem to have 
grasped, despite its noxiousness. Shall 
we not have to have Society for the Pre- 
vention of Expectoration — except into 
sanitary spit-cups? If one could stop the 
spitting habit, prevent the spread of 
consumption, and finally stamp it out, he 
would be greater than a tariff reformer. — 
Medical Record. 



EFFECTS OF ANTISEPTICS ON VIRILITY. 

Attention is called by Dr. Van Den 
Corput {Rev. Tfierap.) to the diminution 
of virile power which he has observed in 
patients to whom he had prescribed anti- 
septics, such as salicylic acid, quinine,, 
menthol, carbolic acid. The author sup- 
poses that these antiseptics act on the 
blood elements, . and on the seminal cells 
as on inferior organisms. The spermato- 
zoids become in effect completely immo- 
bile under the microscope, like all the 
leucocytes, which lose their amoeboid 
movements, and can no longer effect their 
migrations. Salicylic acid acts in the- 
same manner upon the ovary, and causes, 
the lengthening of the menstrual period. 



AVINE TUBERCLE VERSUS HUMAN TU- 
BERCLE. 

Some further experiments are recorded 
by Mr. Charles Riehet on the protection 
afforded against tuberculosis by inoculation 
with cultivations of the bird tubercle. 
This micro-organism, though closely 
allied to the normal microbe, differs from 
it in several important respects. Thirty 
dogs, all in robust health, were taken, nine 
of which were thus inoculated without 
giving rise to any local or constitutional 
manifestations. All the animals . were 
then inoculated with a cubic centimetre of 
cultivation of the active human tubercle 
bacillus. Within a month from the date 
of inoculation every non-vaccinated an- 
imal had succumbed to the disease, while 
the nine dogs previously treated to a dose 
of the bird tubercle remained in good 
health. So far as they go those observa- 
tions possess very great interest, but it is 



June 30, 1892. 



News and Miscellany. 



199 



hardly necessary to point out that it would 
be premature to conclude that we are yet 
in possession of the means of protecting 
human beings againt this terrible malady. 
It is a far cry from the laboratory to the 
isick-bed, and it is notoriously unsafe to 
apply the results obtained in the treatment 
of maladies experimentally induced to ma- 
ladies occurring as part of "a constitutional 
condition. — Med. Press. 



MEDICAL CHEMISTRY. 



A NEW REAGENT FOR ALBUMIN. 

A. Jaworowski proposes a new reagent 
for albumin which detects the presence of 
sGnho part of albumin. (The other known 
reagents, as, for instance, Bodecker's, 
Millon's, acetic acid, and others do not 
detect even the ssisn part.) The reagent 
is prepared after the following formula: 
One part of molybdenate of ammonium is 
heated with 40 parts of water, and after- 
wards mixed with 5 parts of tartaric 
acid, when, if the liquid is not clear, it 
must be filtered. For' examination, the 
urine must be transparent and acid; if it 
is necessary to acidify it, tartaric acid is 
used. For the complete removal of 
albumin from the urine, add a few drops 
•of the reagent and filter it ; after filtra- 
tion, add the reagent again, and so on till 
^ precipitate ceases to be thrown down. 
Too much reagent must not be used at 
once, because the excess may redissolve 
the albumin. By this reagent, also, a 
very small quantity of mucus may be 
detected. — Wiadomosci Farmaceutyczne, 
November 1, 1891. 



A RESEARCH ON THE POISONOUS NA- 
TURE OF MOULDY RICE. 

Dr. J.Sakaki, in tho Sei i-kwai Medical 
Journal, reports the results of his study 
upon the action of mouldy rice. The 
research is particularly interesting because 
it has been thought by students of the 
disease known as hahke that mouldy rice 
was the cause. From the experiments 
which Sakaki has made upon frogs and 
rabbits, it would appear that the poison 
is capable of producing, in the case of 
the rabbit, dyspnoea, rapid pulse, pupil- 
lary dilatation, and paralysis, the animal 
dying in convulsions in from three hours 
to forty-five minutes. In the frog it 
•caused paralysis of the forelegs and loss 



of reflex activity. Finally the batrachian 
was unable to recover its former position 
when placed on its back. Respiration be- 
came feeble and only very severe stimulus 
elicited any response. 



THE FLUORESCENCE OF QUININE CON- 
CEALED BY PHENACETIN. 

From medico-legal investigations con- 
ducted by F. Sestini and R. Campani (IS 
Orosi and Chem. Neivs), they have arrived 
at the following conclusions : The presence 
phenacetin conceals the fluorescence]of sul- 
phuric acid solutions of the cinchona al- 
kaloids, especially when dilute. Aqueous 
solutions of phenacetin are colored yellow 
on the addition of chlorine water and 
ammonia, but mixtures of quinine and 
phenacetin are colored light-blue (methy- 
lene blue). 



NEWS AND MISCELLANY. 



PARADOXICAL. 

The Scientific American says that there 
is much truth in the remark of one who 
observed, "The worst thing about the 
grip is that you are sick with it so long- 
after you get well." 



THE MISSISSIPPI VALLEY MEDICAL 
ASSOCIATION. 

Will hold its Eighteenth Annual Session 
at Cincinnati, Wednesday, Thursday, and 
Friday, Oct. 12th. 13th and 14th, 1892. 
An excellent program, containing the best 
names in the valley and covering the entire 
field of medicine, will be presented. An 
address on Surgery will be delivered by 
Dr. Hunter McGuire, of Richmond, Ya., 
President of the American Medical Associ- 
ation. An address on Medicine will be 
made by Dr. Hobart Amory Hare, Pro- 
fessor of Therapeutics and Clinical Med- 
icine, Jefferson Medical College, Philadel- 
phia. The social as well as the scientific 
part of the meeting will be of the highest 
order. 

The Mississippi Valley Medical Associ- 
ation possesses one great advantage over 
similar bodies, in that its organic law is 
such that nothing can be discussed during 
the sessions save and except science. All 
ethical matters are referred, together with 
all extraordinary business, to appropriate 
committees — their decisions are final and 



200 



News and Miscellany. 



Vol. lxvii 



are accepted without discussion. The 
constitution and by-laws are comprehensive 
and at the same time simple. Precious 
time is not allowed the demagogue or the 
medical legislator. The officers of the 
Pan-American Medical Congress will hold 
a conference at the same time and place. 



GALEN'S HYMN TO THE CREATOR. 

In my opinion, true religion consists 
not so much in costly sacrifices and fra- 
grant perfumes offered upon his altars, as 
in a thorough conviction impressed upon 
our own minds, and an endeavor to pro- 
duce a similar impression upon the minds 
of others, of his unerring wisdom, his 
resistless power, and his all diffusive good- 
ness. For his having arranged everything 
in that order and disposition which are 
best calculated to distribute his favors 
to all his works is a manifest proof of his 
goodness which calls loudly for our hymns 
and praises. His having found the means 
necessary for the establishment and preser- 
vation of this beautiful order and disposi- 
tion is as incontestable a proof of his 
wisdom as his having done whatever he 
pleased is of his omnipotence. — Petti- 
grew's Medical Biographies. 



DEATH OF PROF. MEYNERT. 

The Vienna school has lost another of 
its most ardent workers this week in the 
death of Prof. Meynert. Rumor has been 
for several months past active in pub- 
lishing different vague accounts of the 
professor's state of health, but few had 
any notion of the end being so near. 
Psychiatry had been his life study, and 
his memory will long be preserved in that 
department in connection with his labors 
in the anatomy and physiology of the brain. 
Every ramification of the University has 
passed a tribute in his memory. 

Hofrath Nothnagle, before closing his 
Klinikischen Vorlesung, said that science 
as well as their own alma mater had suf- 
fered a severe loss in Meynart. The men- 
tion of the name instantly brought the 
whole class on their feet. It is surprising 
to a foreign eye the devout adoration and 
demonstrative formality a calamity like 
this excites! While all stood Nothnagel 
continued his eulogistic elegy on the im- 
mortal works of Prof. Meynert, who had 
4milt np a branch of knowledge unknown 



to mankind before his labors began. Psy- 
chiatry before his time was a name with- 
out a meaniug — a chaos with no hope of 
order being restored. About the end of 
last century and the beginning of the- 
present the clinical symptomatology was 
scanty and ill-defined. It is true we owe 
the fundamental origin of psychiatry to 
Griesinger, but Meynert was the spirit 
that gave the department a new impetus, 
He said to the students, ' ' your text-books 
on the anatomy and physiology of the 
brain to-day are very different to those- 
when Meynert commenced his labors. His 
was a poetic conception, not a mere de- 
scriptive brain anatomist; he was a pro- 
found thinker that obtained results not 
in the usual manner step after step, but 
rather as Miiller's description of the poets, 

• Where confusion is greatest, 
Order seems nearest.' " 

Meynert was a great admirer of Shake- 
speare, and poetry in general, which he- 
cultivated in his leisure hours. 

Mental diseases he divided into three- 
large groups — 1st, -the old symptomatico- 
clinic group; 2nd, the anatomical; 3rd,, 
the physiological-experimental. 

Prof. Kahlar opened his lecture with 
the subject which he termed a ''catas- 
trophe," that one of the brightest lumina- 
ries of the University had set for ever. 
His efforts were towards elucidating the- 
nerve centre in two directions — 1st, In 
tracing the nerve fibres to their origin „ 
and may be termed his anatomic labor.. 
2nd. His method of sectional series, or 
localization of the brain. To Meynart 
alone is due the credit of laying the 
foundation of this important section of 
modern knowledge. 

Prof. Zuckerkandl said Meynert had 
opened a new epoch in the history of 
medicine, as to him is due the precise ex- 
pression of symptoms for localization. His 
writings are numerous and varied, but 
his anatomy of the brain is sufficient to 
immortalize his name. 

Profs. Krafft-Ebing, Toldt, Exner, 
etc., gave similiar testimony of Meynert's 
worth. Exner said that Meynert had 
been accustomed for some time past to 
liken the brain to a large globular projec- 
tion draped with a mantle of grey matter 
which reflected the outer world as a bril- 
liant mirror, this mantle was populated 
with images and sensitive beings. — Med 
Press. 



Vol. LXVII, No. 6. 
Whole No. 1849. 



AUGUST 6, 1892 



$5.00 per Annum 
10 Cents a Copy 



A Weekly Journal. 



Established in 1853 by S. W. BUTLER, M. D. 



THE 

MEDICAL AND SURGICAL 
REPORTER 

EDWARD T. R El CHERT, M. D., EDITOR, 

Entered as Second-Class matter at Philadelphia P. O. P. O. BOX 843 



CLINICAL LECTURES. 

- Dr. W. Korte. Berlin, Germany. 

Surgery of the Gall-passages and Li?er. 



201 



Dr. R._ H. M. Dawbarn, New York. N. Y. 
Preparing the Field of Operation; Circumcision; 
Intestinal Obstruction; Appendicitis..... 207 

COMMUNICATIONS . " 

Dr. E. Fletcher Ingalls, A. M., Chicago, 111. 
The Shurly-Gibbes Treatment of Tuberculosis. 210 

Robert Peter, M. D., Canal Dover, Ohio. 
Sepsis, with a Narration of a few Interesting and 
Instructive Cases 221 

A. Bowen, M. D., Nebraska City, Neb. 
Spina Bifida Occulta 225 

J. 31. Shafffr. M. D., Keokuk. Iowa. 
"What's the Matter 223 



LEADING ARTICLES. 

Rectal Gonorrhoea 

The Connection Between Arthritic Diat 
Tuberculosis of the Lungs 




i BOOK REVIEWS .-. 232 



PERISCOPE. 

Therapeutics 232 

Medicine 233 

Surgery ..' 234 

Obstetrics 236 

Gynecology . 237 

Pediatrics 238 

Hygiene 239 

Medical Chemistry * 240 



SELECTED FORMULJE 2?8 NEWS AND MISCELLANY. 



240 



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THE 



MEDICAL AND SURGICAL 
REPORTER. 



No. 1849. 



PHILADELPHIA, AUGUST 6, 1892. 



Vol. LXVII— No. 



Clinical Xectures* 



SURGERY OF THE GALL-PASSAGES 
AND LIVER.* 



By. DR. W. KORTE, 

BERLIN, GERMANY. 



The surgical treatment of diseases of the 
l-passages and liver has been given a 
great impetus during the last decade, and 
has developed into a most successful and 
promising branch of operative surgery. 
The therapeutics advocated in the various 
affections of these parts are by no means 
uniform, but even to-day are subjects of 
discussion and controversy. It would 
appear to me, therefore, that an unbiased 
description of the results obtained in the 
treatment of a series of diseases of the liver 
and gall-passages would be of value to the 
profession. 

These cases are divided into the follow- 
ing groups:— 

t. Diseases of the gall-passages. 

2. Abscess of the liver, 

3. Subphrenic abscess. 

4. Echinococci of the liver. 

5. Injuries of the liver. 

1. DISEASES OF THE GALL-PASSAGES. 

The most frequent cause for surgical 
intervention in the above is the presence 
of stone in the gall-bladder or ducts, and 

* In translating this admirable lecture by Dr. 
Korte, we have made no effort to abridge it, fear- 
ing thereby to mar the completeness of an article 
which must doubtless be locked upon as being 
the most exhaustive monograph on the subject 
in any language. 

The lecture was delivered before the Free 
Meeting of Surgeons, in Berlin, and it appears 
in the German in Volkmann's Collection of Clin- 
ical Lectures. Owing to its length we are 
obliged to publish it in several parts. 



one which has been productive of excellent 
results in these diseases. 

Gall-stones are caused by a precipitation 
of bilirubin, bilirubinate of lime and chol- 
esterin upon the detritus and epithelial 
masses, in places where the gall becomes 
stagnant. This, of course, occurs most 
frequently in the gall-bladder. According 
to Naunyn, the starting point of such a 
concremental formation lies in a " des- 
quamative angiocholitis. " He is inclined 
to believe that a desquamative inflamma- 
tion of micro-organisms is causative of this 
result. Any factor which tends to aug- 
ment a stagnation of the gall, augments as 
well the formation of gall-stone. Among 
these may be principally mentioned the 
conventional dress of women of the present 
day, compressing as it does the region of 
the liver; or again, the compression exerted 
by the abdominal organs during pregnancy. 
These facts amply explain the more fre- 
quent occurrence of gall-stone in women 
than in men. A change of the chemical 
composition of the gall, productive of the 
formation of precipitates, is as yet an un- 
proven theory for the cause of gall-stone. 

Gall-stones may exist without exciting 
any symptoms, either untoward or other- 
wise, and will be only discovered at an 
autopsy by chance. In about one- tenth 
of all the bodies of adults upon which post- 
mortem examinations are made the con- 
cretions are found. They have been found 
to be five times more frequent in women 
than in men. Nevertheless while their 
presence may frequently be productive of 
no harm to the patient, they may occasion 
both severe and dangerous symptoms. In 
the more favorable cases they may be 
pressed through the gall-duct and evacu- 
ated by the bowels. But even this pas- 
sage of the stone through the gall-duct 
occasions most agonizing pain. Those 
frequent gall-stone colics which are unre- 
lieved by any internal medication Langen- 



202 



Clinical Lectures, 



Vol. lxvii 



buch considers as justifiable indications for 
surgical intervention. So soon as a gall- 
stone has attained a certain size, it can be 
no longer passed through the gall-duct, 
and then serious difficulties and dangers to 
the patient are likely to develop. If the 
opening of the ductus cysticus becomes 
occluded, then " retention-cysts " of the 
gall-bladder are developed — hydrops cys- 
tid. fellem — which by means of an increas- 
ing tension and fruitless contractions of 
the gall-bladder are in a position to excite 
serious difficulties. The results are con- 
siderably worse when the stone becomes 
fastened in the ductus choledochus. In 
this event the gall is shut off from the 
bowels, the digestion suffers, and the stag- 
nation of the gall in the liver causes an 
absorption of the biliary substances into 
the blood, occasioning the condition 
known as deletery cholaemia. By means 
of the pressure of the incarcerated concre- 
ments, the walls of the gall-bladder or 
ducts become weakened, and perforation 
can follow. The most fortunate termina- 
tion of this process is where the stone 
breaks its way into the bowel, although 
even this is accompanied by most severe 
symptoms. If a perforation into the ab- 
dominal cavity occurs, the outcome is 
likely to be still more serious. By means 
of a migration of microorganisms a suppur- 
ation of the gall-bladder can occur — an 
empyaema — complicated with all the dan- 
gers consecutive to an intra-abdominal 
suppuration. 

It is not the gall-stone diseases in them- 
selves that call for surgical intervention, 
but rather the various conditions which 
the diseases give rise to, especially when 
internal medication has been proven fruit- 
less or the nature of the complication 
(mechanical obstruction) renders its inu- 
tility obvious. 

In the treatment of this disease there is 
no concurrence between internal medicine 
and surgical interference, but the latter 
steps in as a remedial agent only when 
the former has failed. Here, as in all 
diseases in the cure of which both great 
branches of the healing science may be of 
value, a special education of the physician 
is of great necessity. The surgeon who 
intends to operate in diseases of the gall- 
bladder must intimately understand the 
normal course of these diseases, and the 
physician, on the other hand, must thor- 
oughly understand where and when his 



duties should be supplemented by those of 
the surgeon. With such mutual assistance 
the welfare of the patient— our suprema 
lex—\& best advanced. 

The indications for operative interfer- 
ence may be tabulated as follows : 

1. Frequently recurring gall-stone 
colics which are unrelieved by internal 
medication. This indication is a rela- 
tive one, and must be modified by indi- 
vidual circumstances. 

2. The development of lasting en- 
largements of the gall-bladder, after 
such attacks of colic, is accompanied by 
retention of the bile. Here the exist- 
ence of large concremental formations 
may be taken for granted, which may 
of course give rise to any of the danger- 
ous complications spoken of previously. 
Since the supervention of these most 
grave complications can occur at any 
time and render our surgical interfer- 
ence too late to do any good, I therefore 
consider such enlargements of the gall- 
bladder, accompanied by retention of 
gall, as an indication for operation, es- 
pecially among the working classes, 
among whom physical labor is necessary. 
In case, however, of the existence of re- 
tention and enlargement of the gall- 
bladder, unaccompanied by any colic or 
other symptoms, operation should be 
delayepl. Indeed, the patients in ques- 
tion would, under such circumstances, 
scarcely be expected to submit to an 
operation. 

3. If after severe attacks of colic the 
gall-bladder continues to remain tender 
and enlarged, the existence of an in- 
flammatory process in and around the 
gall-bladder may be accepted, which in 
its turn points to the existence of con- 
cremental formations with a weakening 
of the parts. In such cases, after the 
futile use of internal medication, there 
should be an operation. 

4. When the existence of fever, pain 
and swelling point to the existence of a 
suppurative process, operation should, 
of course, on no account be delayed. 

5. Symptoms of closure of the gall- 
duct, should, after the failure of any 
internal therapy, be regarded as an in- 
dication for operation. 

In the confirmation of diagnosis, and 
the above indications, stress should be laid 
upon the fact that gall-stone colics are 
frequently not recognized as such, but are 



August 6, 1892. 



Clinical Lectures. 



203 



called by all sorts of names, but especially 
el cramps." This fact is called attention 
to by Fiirbringer.* 

Regarding the distinction between tu- 
mors of the gall-bladder, gall-stone dis- 
eases, and all other affections of neighbor- 
ing parts, I would say that frequently 
hemispherically protruding and quickly 
growing tumors of a malign nature can be 
mistaken for distended gall-bladders. As 
an example of this I will cite a case later 
on (Case VII). Continued observation of 
the case, or exploratory incision — which I 
consider fully justifiable in such cases — 
will remove all doubt. A. complication of 
cholelithiasis with carcinoma of the gall- 
bladder or liver can also occur (see Case X), 
Marchand having perhaps been the first to 
call attention to this fact. An enlarged 
and especially movable kidney can be 
mistaken for an enlarged gall-bladder. 
Two of my female patients came to me 
with the diagnosis of " floating kidney." 
In such cases the kidney should be held 
back with the fingers of the left hand, 
while the right hand palpates the region 
of the gall-bladder. This will usually 
suffice to clear away any doubt on such a 
score. The slight movement of the gall- 
bladder during respiration cannot be re- 
garded as any definite mark, since fre- 
quently the kidneys also move sychron- 
ously with the respiration. Further, in 
such cases where the gall-bladder is con- 
siderably enlarged and adherent through 
inflammatory processes, this respiratory 
movement may be entirely absent, or else 
only minimal. In general, the enlarged 
gall-bladder will be found closer to the an- 
terior wall of the abdomen than a renal 
tumor or floating kidney. Again, the 
latter will be more distinctly felt anteriorly 
if pressed forward from the back. When 
the colon is inflated with air it lies in front 
of a renal tumor. Such is, however, not 
the case with tumors of the gall-bladder — 
indeed, it would be impossible. Renal 
colics can, as Fiirbrmgerf has noted, be 
frequently confounded with gall-stone 
colics, especially if only the patient's evi- 
dence is taken into consideration. 

The expulsion of the gall-stones through 
the bowels can only be confirmed by the 
most careful watching of the stools. When 



* Verliandlungen d. Kongressf. Innere Medicine, 
1891. 



in spite of the passage of these gall-stones, 
the gall-bladder still remains enlarged and 
painful, it may be taken for an indication 
that larger concrements still remain, 
which are of such a size as not to be able 
to pass through the gall-ducts. 

Further, a growth in the region of the 
pylorus may be mistaken for an enlarged 
gall-bladder. Careful palpation, how- 
ever, will generally reveal the fact that in 
cases of pyloric tumor, one is able to insert 
the fingers between the edge of the liver 
and the tumor; again, the distention of the 
stomach with either air or water will aid 
in the confirmation of the differential 
diagnosis. When distended the fundus of 
the stomach is pushed forward and the 
pyloric growth will change its position, or 
in certain cases disappear almost entirely. 
By these means any mistake of diagnosis 
in this direction may be entirely avoided. 

Cysts of the liver may also be mistaken 
for the enlarged gall-bladder ;this happened 
to me in a case of closure of the gall duct. 
The history of this patient will be given 
further on (Case XII). There was a round 
prominence somewhat larger than a walnut 
on the edge of the liver, and in the region 
of the gall-bladder. Laparotomy revealed 
the fact that it was a cyst of the liver. 
The shrunken little gall-bladder lay under 
he edge of the liver and could not be felt 
at all. In a few cases I have also found 
some of the liver tissue lying over an 
enlarged gall - bladder. This occur- 
rence was first called attention to by 
Riedel.* 

Right here I wish to warn most emphat- 
ically against the performance of any 
exploratory punctures in cases of enlarge- 
ment of the gall-bladder. This can only 
be without danger when confirming ad- 
hesions to the abdomen. After opening 
the abdominal cavity, I in all cases punc- 
tured the gall-bladder, and found that even 
the punctures of the smallest hypodermic 
needle were sufficient to cause an efflux of 
the bile. The great danger of such punc- 
tures prior to the opening of the abdominal 
cavity will, therefore, at once be seen. 
Although pure and undecomposed gall may 
not have any deleterious effect upon the per- 
itoneum, it must be remembered, as Naunyn 
has proved, that micro-organisms may exist 
in the gall-bladder, especially in empyema 
of this organ. The bacteria found by 



\Loc. cit 



^Berlin Klin. Wochenschrift, 1888, No. 29. 



204 



C Unicoi Lectures. 



Vol. lxvii 



Naunyn and also by me in the gall-bladder 
(see CaseX),and named coli commune excite 
most severe general peritonitis. This has 
been demonstrated by Dr. Alex. Frankel, in 
the Wiener Klin. Wochenschrift, 1891, 
No. 13. 

Since Bobbs, Marion Sims, and Kocher 
first performed the operation of opening 
the gall-bladder for stone, the operation 
has rapidly grown in favor and variously 
modified in its technique. It is termed 
cholecystotomy and may be completed at 
either one or two sittings. In contradiction 
to this procedure, La.ngenbuch in 1882 
recommended cholecystectomy, or excision 
of the gall-bladder in order to prevent 
possible recurrence by the removal of the 
seat of its growth. Oourvoisier, Merideth, 
Spencer Wells, Bernays, and Krister pro- 
duced and performed the operation of so- 
called ' 'ideal cholecystotomy,'"' which con- 
sisted in an incision of the gall-bladder, 
with subsequent suture of the part. These 
constitute the three principal methods 
for the surgical treatment of cholelithiasis ; 
which, however, may be subdivided ac- 
cording to the variations of the details of 
their technique. For the operative treat- 
ment of closure of the gall-duct other 
methods are of value. 

My own experience in the operative 
treatment of gall-stone has been limited 
to twelve cases, eleven of these being 
women, and one man. The proportion 
shows the far greater frequency with which 
the disease is apt to occur in women. 
Besides these, two men came under my ob- 
servation who were suffering from gall- 
stone, and in both cases operation was 
clearly indicated; both patients, however, 
refused operation and I lost sight of them. 
In the case of women, the influence of 
pregnancy was plainly discerned. All of 
them had given birth to children, and 
many gave evidence that the gall-stone 
colics appeared in connection with their 
lying-in period ; although they frequently 
only recognized them as " cramps." In 
six cases there was a dropsy (hydrops) of 
the gall-bladder associated with frequent 
colics. Operation revealed stone in five 
of these cases, but no concremental form- 
ations whatever in one (Case VI). Four 
of the patients suffered with empyaema of 
the gall-bladder. In three of these cases 
stones were formed, but not in the fourth 
case (Case VIII). Finally, three of the 
patients suffered from occlusion of the 



ductus choledochus (one of these suffered 
also from suppuration of the gall-bladder 
and liver, and was operated upon twice). 
Of those operated upon three died — one 
case of occlusion of the gall-duct from 
gradual weakening (Case XII), another 
similar one from suppuration of the liver 
which had existed prior to operation (Case 
XIII), and the third death in a case of 
empyaema of the gall-bladder with stone, 
from carcinoma and suppuration of the 
liver, (Case IX). So far, therefore, I 
have had no death occur from the effects 
of the operation. I was able to dismiss 
all my patients without any biliary fistula? 
and indeed, with a normally acting gall- 
bladder, although in some cases several 
operations were performed. 

The operation of cholecystotomy was 
performed several times — once in a case 
of dropsy of the gall-bladder with stone, 
performed at one sitting, (Case I); four 
times in empyaema of the gall-bladder 
(Cases VIII to XI), at one sitting; twice 
in occlusion of the bile-duct as a prelimin- 
ary operation in cholaemia (Cases XI and 
XIII), at two sittings. It will be seen, 
therefore, that I have performed the oper- 
ation five times at one sitting, and twice 
at two sittings. 

The last modification — the performance 
of the operation at two sittings — has been 
especially recommended by Rieclel. I pre- 
fer the operation as performed at one sit- 
ting when it is possible, and would only 
resort to the double operation when (as in 
Case XII) the gall-bladder is so shrunken 
that it is difficult or even impossible to sew 
up this organ, or when its walls are quite 
fragile, or appear so thin, that it would 
seem that they could not hold the stitches. 
If the gall-bladder can be well reached and 
drawn into the wound, and if its walls are 
strong, I strongly favor the single opera- 
tion. After puncture of the frequently 
tense and distended gall-bladder, in order 
to relieve the pressure against its walls, a 
hermetic closure may be effected. The 
line of incision should first be coated with 
iodoform- collodion, or covered with iodo- 
form vaseline upon a piece of lint. After 
this one way safely cut the gall-bladder 
open and empty it of its contents. I be- 
lieve that, if it is possible, without danger 
to the patient, we are justified in complet- 
ing an operation at one sitting, it- should 
be so performed, and secondly in certain 
cases (such as empyaema, possible necrosis 



August 6, 1892. 



C linical Lectures. 



205 



of the walls of the gall-bladder, and occlu- 
sion of the choledochus) a delay of several 
days is by no means a matter of little . im- 
portance. The biliary fistula occurring 
in cases I and IX was closed plastically 
after a time, by means of loosening the 
walls, suture of the same, and covering 
the whole with the abdominal walls. In 
Case VIII the wound closed spontaneous- 
ly, in Case XI the fistula was removed by 
establishing a communication between it 
and the intestine. Three of the patients 
died in consequence of the primary disease. 

The secretion of gall — as is well known 
— does not occur continually, but period- 
ically, and is especially copious a few hours 
after meals. Some patients apparently se- 
creted no gall during the day time, while 
the flow was copious during the evening 
and night. Contrary to Naunyn's opin- 
ions, I have given Karlsbader salt (1 tea- 
spoonful of the salt in half a pint of water) 
and salicylate of soda (2 to 3 grammes in 
water), in two cases of occlusion of the 
gall-duct, and in many cases of simple bil- 
iary fistula and have observed a decided 
increase in the secretion of the gall. I 
would ascribe to these remedies a decided 
cholagogue action. 

I consider the operation of cholecvstot- 
omy the most rational procedure in empy- 
ema of the gall-bladder, in diseases of the 
walls of the gall-bladder, and, further, in 
occlusion of the choledochus in order to 
establish an exit for the bile and save the 
patient from cholaemia. 

In simple concremenfcal formation in the 
gall-bladder, unaccompanied by any, dis- 
ease of its walls, and where the gall duct 
is not occluded, I prefer a simple opening 
of the gall-bladder, emptying its contents, 
and subsequent closure of the incision — 
the so-called " ideal cholecystotomy." 
This operation was performed by me in 
five cases (Cases II to VI). 

After the opening of the abdomen over 
the distended gall-bladder — and for this 
purpose I prefer a transverse incision 
parallel to the ribs,ratherthana longitudi- 
nal incision, since the former gives a better 
field of vision to the operator — the bladder 
and duct are carefully and directly ex- 
amined by digital palpation, and 'any adhe- 
sions which tend to render the examina- 
tion difficult, loosened. Then the gall- 
bladder is drawn forward as much as pos- 
sible, and the abdominal cavity completely 
protected by sterilized or iodoform gauze, 



which is plentifully packed around the 
bladder. By means of puncture with the 
exploring needle, the character of the con- 
tents of the gall-bladder is determined, and 
if the fluid drawn up into the syringe is 
not putrid, and contains no pus, then the 
patient is inclined somewhat towards the 
right side, and the gall-bladder incised and 
emptied of its contents. The stones are 
usually washed out with ease, or may be 
removed with the "stone-spoon." Diffi- 
culties are met with if the stone is wedged 
in the cyst, and these are only removable 
after considerable effort and great pains 
on the part of the operator. For this pur- 
pose the blunt hook will frequently be 
found a valuable instrument. In one case 
(Case III) the stone was lightly wedged in 
the cyst and all efforts at removal were un- 
availing. Finally, I inserted my finger 
under the gall-bladder in the abdominal 
wound and executed a pressure, as though 
I were squeezing a cherry-pit out of the 
fruit. The stone was thus easily removed. 
It will be readily seen that in this case if 
the abdominal cavity had been closed by 
suture to the gall-bladder this procedure 
would have been rendered most difficult, 
or indeed impossible. The possibility of 
such an occurrence points, in my mind, to 
the superiority of this operation over the 
"ideal cholecystotomy." After the re- 
moval of the deepest stones the golden- 
yellow bile will appear in the bladder, show- 
ing that the communication with the liver 
is now free. In every case I have en- 
deavored to sound the ductus cysticus, but 
the sound is alwavs caught in the folds of 
the mucous- membrane unless the duct has 
been very much distended by the presence 
of stones. This is easily understood since 
the mucous folds are in the form of a 
spiral. So far I have been unable 
to pass a sound from the ductus cysticus 
into the choledochus or even into the in- 
testine. It will be seen, therefore, that 
by means of sounding alone we cannot 
prove the existence of a free passage, while 
palpation from the abdominal cavity is a 
most important aid in determining this. 

A free passage through the choledochus 
— which should be determined before the 
performance of this operation — can only 
be proved or disproved by an examination 
of the faeces, or a digital examination of 
the choledochus. 

After the removal of all concretions 
from the gall-bladder, the latter should be 



206 



Clinical Lectures. 



Vol. lxvii 



disinfected with some solution as little 
poisonous as possible. For this purpose 
a one-half per cent, solution of lysol, or a 
solution of salicylic and boric acids will be 
found applicable. After this the gall- 
bladder is washed out with sterilized water, 
great care being taken to prevent, as far 
as possible, the fluid entering into the ab- 
dominal cavity. If we are convinced that 
the walls of the gall-bladder are intact, we 
can then proceed to close the opening with 
two rows of sutures, similar to those used 
in suture of the intestines. It will be 
found, however, that these sutures are 
more easily applied upon the gall-bladder 
than upon the intestine, since the walls of 
the former organ are considerably thicker 
than those of the latter. 

The first row of sutures brings the edges 
of the incision together, and the second 
closes the peritoneum over it. Whether 
one should use the continuous or inter- 
rupted suture is entirely a matter of pre- 
ference; personally I prefer the latter, 
since I consider that a more exact closure 
of the wound can be effected. For the 
suture material I have principally used 
silk thread, but lately have employed cat- 
gut in its place, for the reason that I have 
found that even when the most stringent 
aseptic measures have been employed the 
silk sutures are apt to slough out. When 
possible, it is well to bring the mesentery 
over the line of suture of the gall-bladder, 
and to fasten it with one or two stitches. 
This membrane becomes so rapidly adher- 
ent as to form an excellent protective 
covering. In the first few cases that I 
operated upon I fixed, or attached, 
the peritoneum to the j^eritoneum at the 
abdominal wound, for safety's sake, but 
later abandoned it without incurring any 
untoward results. In the endeavor to ob- 
viate the possible bursting of the sutures 
of the gall-bladder, Senger and Wolfler 
have practiced a fixation of the gall-bladder 
to the abdominal wound, opening it a few 
days later and emptying its contents; 
Wolfler would not return, or rather, re- 
sink the gall-bladder to its natural posi- 
tion for about nine days. The abdominal 
wound would be closed all but a few 
stitches which were left loose. In this 
opening a strij) of iodoform gauze was in- 
serted reaching to the suture of the gall- 
bladder. After the lapse of four or five 
days this was removed and the abdominal 
wound entirely closed. This precaution- 



ary measure as a guard against the possible 
rupture of the cystic suture, can at all 
events, do no harm. In my experience 
the gall-bladder healed very rapidly in 
four cases, in one a small but rapid closing 
fistula was formed (Case VI). 

(To be continued.) 



NEW OPERATION FOR THE RADICAL 
CURE OF ABDOMINAL HERNIA. 

In a pamphlet (published by I. Artero, 
Home, 1892), Bottini says that to attempt 
to close up, by itself, the passage down 
which the hernia has travelled, or to 
block ud the external orifice by itself, is a 
delusion: the resulting resistance is far too 
weak to withstand abdominal pressure. 
It is the internal orifice, and this alone, 
which should be closed (by sutures). 
This is done by bringing together its 
margins, without disturbing the anatomi- 
cal relations of adjoining structures, 
whether the hernia be oblique or direct. 
The sac is a secondary matter; it may be 
excised — all or part — or left, according 
to circumstances. Whether the hernia be 
free, incarcerated, or strangulated makes 
no difference; the methodical closure of 
the internal opening is the only thing 
aimed at. The hernia is thoroughly 
opened up along its length, the aponeuro- 
sis of the external oblique, and the fibres 
of the internal oblique are reflected on a 
director, and the sac is laid bare, and very 
carefully and thoroughly isolated. Then 
the bowel is returned, the sac being in- 
cised or not according to circumstances; 
in congenital herniae, incision is best 
avoided. Two Hagedorn's needles armed 
with catgut are passed, the first from 
within outwards, embracing not only the 
free margins of the internal oblique and 
trans versalis, but the aponeurosis of the 
external oblique ; the lower suture passes 
well into the thickness of Poupart's liga- 
ment. Then the needles are withdrawn, 
and a finger is introduced into the orifice 
to control the tightness of the threads 
which are now drawn up. The patient is 
directed to cough, and if any bulging be 
felt, a third suture may be inserted ; this 
however, is-* seldom necessary. After a 
fortnight, the patient is perfectly cured, 
no truss or bandage being afterward re- 
quired. Nine femoral, twenty-one in- 
guinal, and one umbilical herniae were 
thus operated on, all with perfect success. 
— Brit. Med. Jour. 



August 6, 1892. Clinical Lectures. 



207 



PREPARING THE FIELD OF OPER- 
ATION; CIRCUMCISION; INTES- 
TINAL OBSTRUCTION; 
APPENDICITIS. 



By DR. R. H. M. DAWBARN, 

XEW TOKK POLYCLINIC. 



Gentlemen: — This patient was presented 
to you at the last clinic, and you remember 
a small fatty tumor was removed from the 
back. The result has not been so good as 
was expected, for there has been some sup- 
puration, an occurrence which is by no 
means common here, but still is occasion- 
ally met with at our clinics, probably from 
the necessarily hasty methods adopted for 
cleansing the field of operation. An inves- 
tigation carried on at the Johns Hopkins 
University has shown that the plan of dis- 
infecting the skin at least twenty -four 
hours before the operation is an eminently 
wise one, as the microbes lodge in the hair 
follicles and in the deeper layers of the 
skin, and are therefore not removed by the 
ordinary washing just prior to operating. 
The best results are obtained where the 
parts are first thoroughly disinfected, and 
then covered with a wet bichloride dress- 
ing for a number of hours. The same in- 
vestigator found that the usual methods of 
cleansing the hands failed to sterilize them, 
and the most approved method of effect- 
ually sterilizing the hands is the one which 
I would recommend you to employ in ster- 
ilizing the patient's skin, as it can be done 
quickly, is very efficient, and is applicable 
to such cases as those upon which' we 
operate here in our clinics. The method 
consists in thoroughly wetting the skin 
with a saturated solution of permanganate 
of potassium in hot water. This stains the 
skin black, but the next step, which con- 
sists in washing with a saturated solution 
of oxalic acid, removes this stain, and the 
process is completed by simply washing off 
the oxalic acid. I am accustomed to carry 
in my satchel, crystals of permanganate of 
potassium and of oxalic acid, which can be 
readily dissolved in water when wanted. 
This method is convenient and cheap, and 
I heartily recommend it to you. • 

As I have been asked to fill this hour to- 
day for a colleague I shall adopt my usual 
custom under such circumstances, and 
speak on several topics which are of such 
practical interest and importance, that cer- 
tain members of the class have requested 



that they be given special consideration. 

CIRCUMCISION. 

First, I shall say a few words about the 
operation of circumcision. I am a firm 
believer in doing this operation upon every 
child. Most genito-urinary surgeons will 
tell you that the Jews have much less ven- 
eral disease than any other race, and this 
cannot be because they are more virtuous, 
but because there is much less surface to 
be infected, and that surface is much less 
sensitive and liable to abrasion. The 
great majority of young men, probably 
ninety-five per cent. , indulge in illicit in- 
tercourse before they are married, and we 
may as well face this fact. We hope in 
our minds that our sons will not belong to 
this great majority, but we know in our 
hearts that they most probably will, and 
hence we should do everything we can to 
avert the evils connected with such habits 
of life. The simplest way of doing a cir- 
cumcision is to slit the prepuce along the 
dorsum, but I do not usually adopt this 
plan, as it is followed by great oedema 
which frightens the friends unnecessarily. 
I believe in removing all the prepuce ex- 
cept enough to cover the corona, and in 
doing this, great care must be taken that 
the mucous membrane be pulled down and 
cut along with the skin, otherwise you are 
likely to have the mortification of remov- 
ing a circle of skin and leaving the mucous 
membrane intact. Having trimmed the 
parts nicely, a running catgut suture 
should be used, and the parts given a coat- 
ing of iodoform collodion, and then dusted 
over freely with baby powder. In the 
adult, there is a tendency to erections, and 
consequent tearing out of the sutures, and 
to obviate this, the patient should be given 
for a day or two before the operation, 
large doses of bromide of sodium, and 
after the operation, the penis should be 
encircled in a coil of small rubber tubing 
through which cold water is kept running. 

INTESTINAL OBSTRUCTION. 

I shall next consider a few points re- 
garding the diagnosis and treatment of 
intestinal obstruction — and first, as to in- 
tussusception. It does not necessarily in- 
volve the entire calibre of the intestine, 
and in many of these cases, which are es- 
pecially frequent among children, a tumor 
can be felt, most commonly in the ileo- 
cecal region. The books usually state 
that it is oblong in shape, but it is rare 
that the abdominal wall is thin enough or 



i 



208 Clinical 

sufficiently relaxed to enable you to dis- 
tinctly map out the shape of the tumor. 
One well-known writer on children's dis- 
eases, says that whenever bloody move- 
ments are noticed in children under two 
years of age, the first thing to be thought 
of is intussusception, and although it does 
not follow that every time a child has 
bloody movements there is an intussuscep- 
tion, the frequency with which this condi- 
tion is overlooked, justifies the warning 
which this writer gives. Volvulus, on the 
other hand, is more frequent in adults 
than in children, and most commonly in- 
volves the region of the sigmoid flexure. 
It seems rather remarkable that it should 
befmet with in grown persons more often 
because in children the sigmoid flexure of 
the colon is proportionately larger than in 
adults. In volvulus, the obstruction is 
well marked ; not even wind passes it, as a 
rule. Of course, it is sometimes high up 
in the small intestine, and then the fre- 
quent passages of faeces from below this 
point might lead you to suppose that the 
obstruction was not complete. 

In most cases of suspected intestinal ob- 
struction, the first thing the average 
practitioner thinks of is some laxative or 
cathartic, and he usually begins with a 
mild one, and then runs through the whole 
gamut to more and more severe cathartics, 
until probably he ends by giving some 
croton oil. Now, aside from the fact that 
croton oil is a very dangerous remedy, 
there are other and better ones which will 
suffice where any cathartic is appropriate. 
Just think that if the croton oil happens 
to be retained, what an irritant action it 
must exert ! The only laxative I would use 
would be some saline, such as Epsom 
salts, Eochelle salts, or Hunyadi water; 
and if these did not act as purgatives, they 
will be gradually absorbed through the wall 
of the gut, and be excreted through the 
kidneys, and therefore they do not possess 
the objectionable features of other cathar- 
tics. If such laxatives do not relieve the 
obstruction, I should next think of a high 
rectal enema, which may be given in 
various ways. The plan which I believe 
to be original with me, consists in warm- 
ing a siphon of carbonic acid water, attach- 
ing a rubber tube to the outlet tube of the 
siphon, and introducing this rubber tube 
high up into the rectum. By pressing the 
trigger on the siphon, you can obtain the 
effect of both the gas and water under 



Lectures. Vol. lxvii 

pressure, and this pressure can be easily 
regulated in the same way. After discuss- 
ing this subject before the class about two 
years ago, one of the gentlemen came to 
me and related a case of severe intestinal 
obstruction, where after the usual injec- 
tions had failed, at the suggestion of one 
of the physicians present, the patient was 
inverted, and nearly two quarts of glycerine 
introduced into the rectum with a foun- 
tain syringe, and the patient kept in that 
position for half an hour. At the end of 
this time, there was a remarkably copious 
discharge of faeces, and the obstruction was 
completely relieved. We know that 
glycerine is a very powerful exciter of 
peristalsis, and the method is certainly 
worthy of a trial before resorting to the 
knife. Another method which I have 
never tried, but which is recommended, 
consists in washing out the stomach; it is 
said to act by exciting peristalsis, and I 
presume it might be successful in mild 
cases. We now come to the ques- 
tion of operation. If the patient re- 
fuses operation, I would desist from 
the use of laxatives, and would 
administer opium or similar remedies, and 
await events, for one well-known text- 
book says experience has shown that a large 
percentage of these cases of intussusception 
recover. If you do not operate early, you 
may expect dangerous complications, for 
there are usually in the later stages, firm 
adhesions. In both volvulus and intus- 
susception, the best treatment in my 
judgment is to cut out the affected portion 
and make an artificial anus, and a few 
weeks later, operate for the restoration of 
the continuity of the gut, preferably by 
intestinal, anastomosis. It is a great 
mistake to endeavor to restore the contin- 
uity of the gut at the time of the primary 
operation, although this was the common 
practice only four or five years ago. Of 
course, in advocating early operation in 
these cases, I take it for granted that those 
attempting such operations are thoroughly 
competent to carry out the full technique 
of aseptic surgery. Where there is much 
distention of the intestine, it may be 
necessary to puncture coil after coil of 
intestine, for, strange to say, you cannot re- 
move any large amount of gas by punctur- 
ing a single coil. It is for this reason, 
that I have given up Senn's hydrogen gas 
test for intestinal perforation. Theo- 
retically this is a beautiful test, but ex- 



August 6, 1892. 



Clinical Lectures. 



209 



perience shows that practically, the test 
does not always work, as the perforation 
is sometimes obstructed by a hard mass of 
faeces. In a number of instances in which 
this test was successful in revealing a 
perforation of the intestine, it was found 
that the inflation of the intestine with 
the hydrogen gas had caused so much dis- 
tension, that coil after coil required to be 
punctured in order to facilitate the subse- 
quent steps of the operation. Finally, in 
experimenting with this test on the cada- 
ver, I had an experience which led me to 
abandon it altogether. I had produced 
several bullet wounds in the intestine, and 
was endeavoring to inflate the gut with 
hydrogen gas. I allowed the gas to pass 
through for sometime, according to the 
usual method in order to expel all air, but 
on applying a lighted match to one of the 
perforations in the intestine, there was a 
violent explosion which would have been 
extremely disastrous had the test been 
performed on the living subject. The 
explanation of this subject was simply that 
sufficient air had gained entrance through 
the perforation to form an explosive mix- 
ture with the hydrogen gas. The test, 
therefore, is both unsafe and unreliable. 

APPENDICITIS. 

I shall now say a few words about ap- 
pendicitis, a term which embraces what 
was formerly called typhlitis and peri- 
typhlitis. Dr. Mc Burney claims that in 
ninety-five per cent of these so-called 
cases of typhlitis, or perityphlitis the troub- 
le is primarily in the appendix. It was 
because operations were performed formerly 
at so late a stage that it is only very lately 
that we learned that the appendix is not 
an intraperitoneal viscus. We know now 
that it has in almost every case a dis- 
tinct though short mesentery. The common 
idea that seeds and other foreign bodies of 
some kind or another are the cause of this 
condition is a fallacy. Prudden states 
that he has never found in his large ex- 
perience a seed or pit, the starting point 
being almost invariably a faecal concretion. 
Normally, the blind end of the appen- 
dix is held upward so that it can 
empty itself by gravity, but in almost 
every case examined pathologically, the 
blind end has been found hanging down- 
ward, thereby inviting, as you see, the 
retention of fsecal matter long enough to 
cause irritation. 

As regards the symptoms, the patient 



has pain and tenderness, greatest at a 
point midway between the navel and the 
anterior superior spine of the ilium. 
This was first described by McBurney, 
and has been called " McBurney' s 
point." At one time, he claimed that it 
was pathognomonic of this condition, but 
we know that this is not true. This 
point is supposed to be about opposite the 
apex of the appendix, and hence this is 
the mid-point of the incision. The symp- 
toms may be briefly summarized as fol- 
lows: (1) This special point of tender- 
ness; (2) rigidity of the abdominal mus- 
cles on the affected side, as compared with 
those of the opposite side; (3) a drawing 
up of the thigh on the affected side ; (4) 
the presence of a tumor, provided you see 
the case sufficiently late, or if the patient 
be etherized, so that the rigidity of the 
muscles is overcome; (5) the presence in 
most cases of a certain amount of fever: 
and (6) if the pus be present, possibly 
rigors. On these half dozen symptoms, 
you can base your diagnosis of appendici- 
tis. The condition of the bowels has 
nothing to do with the diagnosis, because 
the trouble is in the appendix, although 
usually the bowels are somewhat consti- 
pated. The degree of fever is also not of 
much importance. The most inrportant 
point is, shall we operate whenever these 
symptoms are present? We all know that 
many of these cases get well, but unfortu- 
nately a great many do not recover. Poul- 
tices and iodine accomplish nothing; mor- 
phine does harm instead of good by mak- 
ing the patient so comfortable that he will 
refuse an operation which might save his 
life. The presence of a tumor would in- 
duce me to operate in every case, because 
that means pus, and you cannot tell by 
what route it will be discharged ; but if no 
tumor is present, I would operate when- 
ever/ there is shock, as shown by cold ex- 
tremities, an abnormal ratio between the 
pulse and respiration on the one hand, 
and the temperature on the other. For 
instance, if the temperature were 101° or 
lower, the pulse 120 or 130, and the res- 
pirations proportionately increased, per- 
foration or threatened perforation is indi- 
cated in most cases. Having decided to 
operate, you must make preparations as 
for an ordinary laparotomy, as you are 
going to expose the intestine for several 
inches. It is very common to find the 
small intestine covering the field of opera- 



210 



Communications. 



Vol. lxvii 



tion, and much valuable time is consumed 
in trying to get the intestine out of the 
way. The following point in technique 
will aid you greatly at this stage. Turn 
the patient over so that he rests with the 
left side against the bed or table, and the 
field of operation is uppermost; then seize 
the edge of the gut in the abdominal open- 
ing with a retractor, and draw it forward 
away from the spine. This will make a 
cavity into which the intestines will fall 
out of the way, while the caecum which 
has a very short mesentery cannot follow, 
but must remain uppermost. You next 
apply two ligatures and cut between them. 
The mucous membrane and the stump of 
the appendix should be scraped with a 
spoon, and the stump disinfected by touch- 
ing with a drop of pure carbolic acid. If 
you find adhesions blocking off this por- 
tion from the general peritoneal cavity, be 
most careful not to break them up. If 
the appendix cannot be readily reached on 
account of adhesions, I carefully wash out 
the cavity and pack it instead of breaking 
up the adhesions. This is very important. 
Drainage is established anteriorly, either 
by a glass or rubber tube, with gauze both 
around and inside of the tube. Only the 
extremities of the incision are closed, the 
packing being brought out through the 
middle portion. The packing is fre- 
quently changed, the frequency depending 
upon the temperature and the amount of 
the discharge. When suppuration is 
ended, freshen up the edges of the wound, 
and unite them by sutures, carefully in- 
cluding the muscles, in order to avoid the 
liability to hernia. When the accumula- 
tion of pus is posterior, make a small 
opening upon the dressing forceps, close 
to the ilium posteriorly, enlarge this with 
the forceps, and draw the drainage tube 
in from behind, and completely close the 
anterior wound. This is an excellent 
method of drainage, because the drainage 
is assisted by gravity, and the tendency to 
hernia is avoided. 



SPIRITUS OPHTHALMICUS. 
This is said to be a remedy of great 
value in chronic conjunctivitis. The old 
English writers on ophthalmology used it 
extensively : 

T> Spiritus camphor. 

-IX Spiritus viui gallici aa Si. 

Spiritus lavender. 

Spiritus rosemary aa Sij. 

M. Sig —Eye spirits, to be used only externally over 
the closed eyelids. 



Communications, 



THE SHURLY-GIBBES TREATMENT 
OF TUBERCULOSIS.* 



By E. FLETCHER INGALLS, A. M., 
M. D., 

CHICAGO, ILL. 



The iodine and gold and sodium bich- 
loride treatment of tuberculosis, more com- 
monly known as the Shurly-G-ibbes treat- 
ment, originated with Drs. E. L. Shurly, 
of Detroit, and Heneage Gibbes, of Ann 
Arbor, in the fall of 1890, and was the 
outcome of numerous experiments which 
they have made on animals. 

Owing to the furor created by the an- 
nouncement that Koch had discovered a 
remedy for tuberculosis, some enterprising 
newspaper men who had heard of Dr. 
Shurly's experiments, succeeded in obtain- 
ing from the report of the Medical Society of 
Detroit and from the Harper Hospital cer- 
tain facts with reference to his researches ; 
these facts when amplified and illuminated 
by the brilliant imaginations of the report- 
ers, made many columns in the daily press, 
which were sent out to all parts of the 
country. The craze over Koch's tubercu- 
lin kept alive the interest in Shurly's 
treatment and caused numerous physicians 
in various parts of the country to give it a 
trial. 

In the early part of January, 1891, I 
visited Detroit to investigate Dr. Shurly's 
method and was so favorably impressed by 
the result of hi